Title of Course: School Refusal Behavior: Children Who Can’t or Won’t Go to School
CE Credit: 4 Hours
Instruction Level: Intermediate
Author: George B. Haarman, PsyD, LMFT
Abstract:
This course will break down the distinction between truancy and school refusal and will examine a number of
psychological disorders that may be causing - or comorbid with - school refusal, including separation anxiety,
generalized anxiety, social phobia, panic attacks, major depression, dysthymia, ADHD, and oppositional defiant
disorder. Completing the course will assist you in performing a functional analysis of school refusal to determine the
motivation and particular reinforcement systems that support the behavior. Specific intervention strategies will be
reviewed, with a focus on tailoring and adapting standard approaches to specific situations. Participants will be given
the opportunity to review several case studies and develop a sample intervention plan for cases of school refusal.
Learning Objectives:
1.
2.
3.
4.
5.
6.
Identify the unique behavioral and clinical features of children who refuse to attend school
Name the four types of school refusers
Identify the functional purposes served by school refusal
List comorbid disorders that frequently underlie school refusal
Describe individual, family, and pharmacological treatment approaches to school refusal
Develop individualized treatment plans for the various types of school refusal
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School Refusal Behavior: Children Who Can’t or Won’t Go to School
Truancy vs. School Refusal
Failure to attend school is a problem that has existed for as long as there have been schools. When the first organized
school opened its doors, undoubtedly there was a child who refused to attend. Early literature labeled these children as
“truant,” derived from the French word truand, meaning beggar, parasite, lazy person, naughty child, or rogue.
However, in addition to those children who refused to attend school in an antisocial fashion, there was a gradual
recognition of a subset of children who were absent from school who did not fit the typical patterns or dynamics of a
truant. For this subset of children, school absences were more emotionally-based than oppositional. In an early
definition of anxiety-based absenteeism, Broadwin (1932) defined some children as exhibiting a set of school refusal
behaviors that “are an attempt to obtain love or escape from real situations to which it is difficult to adjust.” Eventually,
this group of children was identified as "school phobic" and their absence from school was identified as "school phobia."
School phobia was identified in the 1940s as a psychoneurotic disorder characterized by overlapping phobic and
obsessive tendencies (Johnson et al., 1941). School phobia was described as fear-based school non-attendance in
response to a specific set of stimuli or to a situation that was a part of attending school. In many cases, it also involved
separation anxiety, which was present before the advent of attending school, and was comorbid with generalized
anxiety, somatic complaints, depression, and family conflict. Early thinking identified three essential elements of school
phobia:
1) acute child anxiety with hypochondriacal and compulsive elements resulting from a wish for dependence,
2) increased anxiety in the child’s mother (primary caretaker) as a result of some identifiable stressor, and
3) a historically unresolved, overdependent mother-child relationship and regression to a period of mutual
satisfaction.
An alternative, less clinical term, “school refusal behavior,” was later used in Great Britain to define similar problems in
children who did not attend school because of emotional distress, but who did not appear to be pathological in other
respects. The term school phobia was felt to be overly clinical and psychopathological, and the term "school refusal" was
adopted as a broader encompassing term.
One difficulty with the professional literature, which has engendered some confusion, is the broad variability in the
terminology associated with this phenomenon and the lack of precision with which the terminology has been used.
Kearney (2008b) attempted to provide some clarification and precision with definitions of specific terminology. He
defines “absenteeism” as a legitimate or illegitimate absence from school or class. He estimates that 80% of the children
absent from school are absent for legitimate reasons. The remaining 20% are "school refusers," which he defined as
children who do not fully attend school and have no reasonable or justifiable circumstances for the absence. This
illegitimate absenteeism may be child-motivated or parent-motivated, i.e. requiring the child to stay home to babysit
younger siblings or care for an elderly grandparent. Parent-motivated absenteeism is often referred to as "school
withdrawal."
There are a variety of terms used to refer to a child-motivated absence, contributing to some of the confusion. These
include: truancy, school refusal, school phobia, or dropping out. Truancy has different meanings, including a legal
definition, which may vary from jurisdiction to jurisdiction. It generally refers to an illegal or illegitimate absence from
school or an unexcused absence without parental permission. School refusal generally refers to anxiety-based
absenteeism. These children have difficulty going to or remaining in school and are often described as fearful, anxious,
sad, timid, and shy. However, significant overlap exists between youth traditionally described as truant and those
labeled as school refusers. Many youth who refuse school show a combination of anxiety-based and acting out behavior.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 2 of 48
School refusal is sometimes linked to more specific concepts such as school phobia, separation anxiety, and dropping
out. School phobia refers to fear-based absenteeism, in which a child is specifically afraid of something related to school
attendance, like a bully, an animal in the classroom, the lunch room, or the bus ride. The term school phobia is used less
frequently in the professional literature. Kearney (2008b) has suggested that “it is best to avoid using this term when
consulting with fellow professionals and parents.”
Separation anxiety refers to the difficulty of the child - and sometimes the parent – with separation in key situations like
going to school or staying with a babysitter. Fear and separation anxiety are very frequently among the components of
school refusal. School dropout or dropping out refers to premature and permanent departure from school prior to
graduation. According to the National Center for Education Statistics (2008), the dropout rate for 16-24 year olds in the
United States is 8.0%.
Kearney (2008a) has suggested that the most appropriate terminology is one that deals with all youth with problematic
absenteeism under one rubric called "school refusal behavior" and identifies them as "school refusers." School refusal
behavior refers to child-motivated refusal to attend school or difficulties with remaining in class the entire day. The term
school refusal behavior refers to a collection of behaviors along a continuum, ranging from the child who attends school
but is under duress and pleads for non-attendance to the child who is completely absent from school for an extended
period of time.
A review of the literature would reveal that there appear to be two distinct dynamics and characteristics that
differentiate the typical truant from a school refuser (Kearney, 2008b). This dynamic can be readily seen in the following
chart, which illustrates the distinctions between those children who are school refusers and those who operate out of a
truancy dynamic:
Behavioral Characteristics of School Refusers and Truants
School Refusal
Truancy
Severe emotional stress about attending school: may include
anxiety, temper tantrums, depression, or somatic issues
Lack of excessive anxiety or fear about attending school
Parents are aware of absence or the child convinces parents to
allow him to stay at home
Children often attempt to conceal their absence from parents
Absence of significant behavioral or antisocial problems
Frequent antisocial behavior, often in the company of
antisocial peers
During school hours, the child stays home because it is safe
During school hours, the child is somewhere other than home
A willingness to do homework and complies by completing
work at home
Lack of willingness to do schoolwork or meet academic
expectations
According to Kearney (2001), school refusal is “child-motivated refusal to attend school or difficulties remaining in
school for an entire day.” Berg (1996) defined school refusal as severe difficulty attending school often resulting in a
prolonged absence; severe emotional upset when faced with the prospect of attending school; staying at home with the
parents’ knowledge; and an absence of antisocial characteristics. School refusal would not include absences because of
chronic physical illnesses, absences motivated by parents, homelessness, chronic runaway status, or non-child initiated
absences. Berg (1997) further expanded the concept as a condition characterized by reluctance or refusal to go to school
by a child who: 1) seeks the comfort and security of home, preferring to remain close to parental figures; 2) displays
evidence of emotional upset or unexplained physical symptoms at the prospect of going to school; 3) manifests no
severe antisocial tendencies; and 4) does not attempt to conceal the problem from parents. King and Bernstein (2001)
expanded the concept to include school attendance difficulty associated with emotional distress, especially anxiety and
depression.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 3 of 48
Kearney and Silverman (1996) further expanded the definition of school refusal to include those children who have
difficulty remaining in school for the entire day. They identify school refusal as a continuum of behaviors, which includes
consistently missing school all the way to rarely missing school, but attending under extreme duress. School refusal
includes those who:
1. Are completely absent from school
2. Initially attend and then leave during the school day
3. Attend for all or part of the day, but only after a behavioral incident at home or on the way to school (tantrum,
vomiting, etc.)
4. Display unusual distress during the school day and plead for nonattendance or create excuses to go home
In addition, school refusal is often viewed on a continuum of severity and chronicity. Many children will experience a
brief period in their life during which attending school is particularly difficult or emotionally overwhelming. For many
youth, this is a brief condition that spontaneously resolves itself after a few days. For others, once the problematic
behavior appears, it becomes self-reinforcing and will persist for long periods of time without significant intervention.
Kearney and Silverman (1996), Silverman and Kurtines (1996), and Kearney (2001) identified three levels of severity of
school refusal:
1. Self-corrective school refusal: initial absenteeism remits spontaneously within a two-week period
2. Acute school refusal behavior: absenteeism that lasts from two weeks to one calendar year
3. Chronic school refusal behavior: absenteeism that lasts longer than one calendar year and overlaps two school years
Setzer and Salhauer (2001) further expanded the identification of school refusal related to the degree of severity and
chronicity when they outlined four varying types of school refusal behavior:
•
•
•
•
Initial school refusal behavior: lasts for a brief period (less than two weeks) and may resolve without intervention
Substantial school refusal behavior: occurs a minimum of two weeks and requires some form of intervention
Acute school refusal behavior: two weeks to one year, being a consistent problem for a majority of the time
Chronic school refusal behavior: interferes with, or overlaps, two or more academic years
Characteristics of School Refusers
Children present with many different reasons for refusing to attend school. In many
instances, separation anxiety disorder or a history of separation in the past may create an
underlying anxiety about being away from home or parental figures, which school
attendance - of course - requires. Many children in the foster care system have
experienced significant anxiety because of the physical and emotional separations that
typically occur. These separations create an underlying anxiety that makes attending
school extremely difficult.
Other children who become anxious about attending school may be struggling with the
fear of losing a parent through illness, divorce, or death. In many instances, the school
refusal may actually begin after the parent recovers from an illness during which the child
remained at home rather than attending school. The absence continues despite the lack of a threat from the parent’s
illness. These children may engage in magical thinking or create disaster scenarios, in which something bad will happen
to a parent if they are not there to monitor or prevent the disaster. Fear of physical and emotional abandonment may
make it difficult for the child to have his or her parents out of sight and out of their “control.” Many children who refuse
school may have experienced an unstable family situation in which frequent physical moves or family changes have
occurred. This creates an underlying anxiety about not being able to control the home situation while they are at school.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 4 of 48
Changes in the stability of the system at home and in the family, such as deaths in the family, divorce, moves to a new
house, separations, transfers to another job or community, or jealousy of new siblings, can all cause a family system to
be so unstable that a generalized state of anxiety may result. Some children may attempt to manage or contain this
instability by a reluctance or refusal to attend school. A family system in which parents are overly anxious themselves
may actually transmit unspoken messages to the child about attending school. The child may view the anxiety of the
parents as being caused by their attendance at school and may feel it is their fault that the parent is anxious about the
child attending school. The youth may feel that they are obligated to “take care of” the anxious parent by staying at
home, thereby making the parent feel more comfortable and secure.
The root anxiety the school refuser is experiencing in a school situation may vary
significantly according to age (King and Bernstein, 2001). Younger children may feel
more anxious about being separated from caregivers, fear a teacher, become anxious
about riding the bus, or fear being picked on by older children. Frequently middle/high
school refusers have concerns about academic performance or worries about making
friends, eating in the cafeteria, using the school bathroom, changing for gym, being
called on in class, or being made fun of or ostracized by peers. For some children there
are legitimate fears of bullies, gangs, school violence, or being ostracized and ridiculed.
Behavioral symptoms are also variable in their presentation, but for many children they may include fearfulness, panic,
crying, temper tantrums, threats of self-harm and somatic complaints. Many children who are school refusers may
utilize a variety of verbal or even physical protests each morning before school. Their disruptive behaviors may be a
“proactive” attempt to avoid going to school. By being so disruptive or behaviorally out of control, the child hopes that
parents may acquiesce and allow the child to stay at home. These behaviors may be openly defiant, excessively
disruptive, and may escalate to clearly unacceptable behaviors as a desperation move to avoid school attendance. For
some school refusers, their behavior may be more passive as evidenced by lethargy, delays, or stalling. They can also
take on a more “passive aggressive” quality as evidenced by the child who “misses the bus” or who is chronically late
due to “oversleeping.”
One strategy employed by many school refusers to avoid attending school is to display physical illnesses or bodily
symptoms. These symptoms may be factitious in nature or may truly be experienced as psychosomatic correlates of
their emotional or psychological discomfort. School refusers frequently have a large number of physical symptoms that
can include autonomic, gastrointestinal, and muscular symptoms. Dizziness, headaches, trembling, heart palpitations,
chest pains, abdominal pain, nausea, vomiting, diarrhea, back pain, and joint pain without any organic basis are
frequently experienced by school refusers. In some situations, school refusers may experience symptoms that are
contradictory in nature or cannot exists simultaneously, involving both the parasympathetic and sympathetic nervous
systems.
In other cases, the school refusal behaviors may be a part of an identifiable family interaction pattern. A variety of family
characteristics have been identified as associated with school refusers (Kearney & Silverman, 1995). One of the more
obvious dynamics is the existence of overdependence between parent and child. This lack of autonomy on the part of
the child or unwillingness of the parent to allow for independent functioning may produce significant anxiety due to the
fact that the act of attending school calls for separation and autonomous functioning. The youngest child in the family is
particularly vulnerable to school refusal, probably as a result of overdependence or enmeshment issues (Kearney and
Silverman, 2002).
The opposite extreme is also seen in families of school refusers whose families display extreme detachment. These
children often feel vulnerable and lacking in support to deal with the challenges of attending school. Many children who
struggle with attending school come out of families where physical and social isolation is common. For these children,
the social aspects of attending school are often overwhelming and escape behavior may ensue. A number of other
family dynamics have been identified as highly correlated with school refusal, including overprotective parents, anxious
mothers and ineffective fathers, and high levels of marital tension.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 5 of 48
Kearney and Silverman (1995) identified six types of families of school refusers:
1) Enmeshed
2) Conflicted
3) Detached
4) Isolated
5) Mixed
6) Healthy
1) Enmeshed families - The dominant aspect of these families is an apparent lack of boundaries and individual
dynamics that prevent boundaries from being recognized or honored. Parents in these situations are characterized
as overprotective and cannot tolerate their child experiencing any difficulty or discomfort. These parents respond
too quickly and disproportionately to any unpleasant situation that the child may experience at school rather than
allow the youth to work through his own difficulties. An individual parent or both parents in the enmeshed family
may be overindulgent, not setting any limitations on behavior and allowing the child too much decision-making
authority. The child may exhibit symptoms that serve the dual purpose of avoiding school attendance while at the
same time eliciting a strong nurturing and pampering response from parents. Enmeshed families have a strong need
to insure that children remain dependent, and any attempts at developing autonomy and self-sufficiency are overtly
or covertly discouraged.
2) Conflicted families - In many families, the level of hostility, violence, and conflict often threatens the stability of the
family. These families are constantly in conflict, and in many instances violence, threats, and coercion are the forces
that maintain the connections between family members. School refusal and the school refusing child can serve as a
distraction to insure that the level of conflict does not reach critical mass and threaten the existence of the family. A
child with school attendance issues in some situations becomes the “lightning rod” for the family conflict. Having a
family member absorb the family conflict leaves the family at a systemic state of homeostasis that does not threaten
the dynamic of the family. The level of conflict often keeps the system under constant threat, in chaos, and full of
uncertainty. This family “background noise” creates anxiety in all family members. For the school refusing child, this
heightened state of constant anxiety may make adapting to the normal stresses of school attendance overwhelming
and unbearable.
3) Detached families – Many school refusers exist within a family environment with little real interpersonal connection
between members. These youth are raised in a home with one or both parents physically or emotionally absent, in
which the school refuser may have very little sense that the adults in her life will be there for them if needed.
Increasingly, children are being raised by other relatives or as a part of the foster care system and have limited
emotional connection to their “family” of caretakers. In these situations, there is often little involvement among
members and many youth are left with the feeling that no one “has my back” or will come to my assistance in
dealing with the problems that I might be experiencing at school.
4) Isolated families – Children who live in rural or isolated settings may experience a great deal of difficulty in adjusting
to school attendance. Many of these children have had little contact with individuals who are not family members or
a part of their small group of friends and neighbors. Exposure to a new and unfamiliar setting and new and
unfamiliar people can be quite anxiety producing. Having to adapt to and interact with youth and school personnel
who come from different socioeconomic backgrounds, cultures, or value systems can be a threatening experience.
Even children who live in metropolitan areas may feel a social isolation if their family has limited contact with the
larger community. Increasing their level of social interaction in the face of having had limited opportunities to
develop or practice these skills outside the family may cause them to struggle socially, leading to further social
isolation.
5) Healthy families – It would be a mistake to assume that a child who is refusing to attend school must come from a
dysfunctional family. Many school refusers come from very healthy and functional family situations, but may have
difficulty attending school due to a specific situation like a punitive teacher, a bully, or other stressors. Children who
struggle academically may also be school refusers, since they find little reward or reinforcement in attending school,
despite parental encouragement and support.
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6) Mixed traits – The families of some school refusers may display two or more traits that are associated with school
refusal. Enmeshed families are often also highly conflictual due to a lack of honoring and respecting appropriate
boundaries. Many isolated families also display a high degree of detachment within individual family members.
Demographic Characteristics of School Refusers
According to the U.S. National Center of Education Statistics (2006), 5.5% of students are absent
on a typical school day. In a typical month, 19% of fourth graders and 20% of eighth graders
missed at least three days of school; 7% of fourth graders and 7% of eighth graders missed
more than five days in a month. Rates are higher in inner-city schools as compared to rural
schools, higher among schools where a majority of students are eligible for the free lunch
program, higher in public schools as compared to private schools, greater in high schools than
middle and elementary schools, and more prominent in large schools as compared to smaller
schools. Duckworth and DeJung (1989) have estimated that the rate of youth absent without a
valid excuse is about 4%. They also estimate that 5% to 10% of all school children are late in the morning or miss part of
the day and that 6% to 10% of those attending school are attending under identifiable anxiety based duress.
A “best guess” is that 5% to 28% of children display some aspect of school refusal behavior at some point in their lives
(Kearney, 2007b). Kearney also estimated that for any given day, 2-5% of enrolled children are school refusers. School
absenteeism and school refusal prevalence rates rival those of major childhood behavior disorders, such as depression,
substance abuse, oppositional defiant disorder, and attention deficit hyperactivity disorder (Costello, Eger, and Angold,
2005). King and Bernstein (2001) reported that school refusal is equally common among boys and girls, but female
school refusal may be more fear based, while male school refusers may be more oppositional based. Ollendick & Mayer
(1984) indicated that school refusal can occur at all ages, but peaks at 5-7, 11, and 14 (kindergarten, 6th grade, and 9th
grade). Periods of transition, such as attending a new school, moves to a new home, new brother or sister, or a sick
parent, often increase the likelihood of school refusal (Kearney & Albano, 2007). No socioeconomic or gender
differences are noted. There also does not appear to be a relationship to academic or intellectual ability, although
prolonged school refusal will eventually impact academic achievement (Egger, Costello, & Angold, 2003). Kearney and
Albano (2007) reported that generally children age 5 to 11 tend to refuse school to avoid negative affect and/or to
receive attention, while youth 12 to 17 tend to refuse school to escape aversive social or evaluative situations or to gain
tangible rewards.
Long-Term Sequelae
While school refusal is often minimized as “a phase,” a stage of development, or a normal right of passage, it would
appear that in many situations school refusal is a predictor of more lasting issues that can persist into adulthood (King,
Ollendick, & Tonge, 1995). While school refusal may not be causative of adult problems, in many situations school
refusal that is not addressed emphatically is predictive of later problems. A review of the literature (Kearney, 2008b)
indicated a number of studies indicating a relationship between school refusal and academic underachievement,
dropout rate, increased psychiatric care, and autonomy issues. A reluctance to physically leave the family of origin,
difficulty emotionally leaving the family of origin, and delinquency and criminal offenses have been correlated with early
school refusal (Bernstein et al., 2001 and Flakierska-Praquin et al., 1997). Kogan et al. (2005) found that early
absenteeism is associated with dropping out of school, an event which leads to a disconnection from school-based
health programs, economic deprivation, and marital, social, and psychiatric problems in adulthood.
School refusers would also seem to be at risk for developing substance abuse issues. Chou et al. (2006) and Halfors et al.
(2006) have demonstrated a correlation between alcohol abuse, school absenteeism, and school refusal behaviors.
Roebuck, French, and Hurrelmann (1999) have also established a correlation between school refusal and early marijuana
use.
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Internalizing versus Externalizing
School refusers tend to display behavior that is school avoidant utilizing an internalizing/externalizing continuum. For
some children, school refusal is a way of internalizing aspects of their environment that make them feel uncomfortable
or fearful. Fears (specific phobias), anxiety, somatic complaints, depression, and general negative affectivity are
frequently experienced by the school refuser. Somatic complaints are frequently reported by school refusers. Freemont
(2003) indicated that 56% of school refusers sampled displayed a primary diagnosis of anxiety disorders, including
generalized anxiety disorder (36.5 %), separation anxiety (27.0 %), social phobia (33.6%), and other anxiety disorders
(PTSD, OCD, Agoraphobia, etc). They also noted that approximately 66% of all school refusing youth presented with
some somatic complaints.
Other school refusers tend to externalize symptoms through a number of “acting out” behaviors, including a variety of
physical, verbal, and passive/aggressive behaviors, and temper tantrums. These are assumed to be triggered by internal
psychological factors. These behavioral issues can take a number of forms and serve a number of purposes. Many
behaviors, such as clinging to a parent or being physically aggressive toward a teacher or other students, may
“advertise” the nature of the anxiety. Externalizing behaviors like hiding, repeating the same question or statement,
constantly talking, or making excessive demands may be a method of avoiding or ameliorating an anxiety-provoking
situation. Tantrums, suicide threats, threats of self-harm, or threats of harm to others are guaranteed to garner
attention from parents, school personnel, and others. A variety of classroom misbehaviors may be attempts to escape
the school setting or force parent contact for reassurance. For many school refusers, disruptive behaviors may be a test
of parental resolve or a manipulation for concrete rewards (bribes, bargaining, or rewards following initial noncompliance). Behaviors may include verbal or physical threats to intimidate parents into acquiescence or to rescue the
child from the school situation.
Continuum of School Refusal Behavior
As a group, school refusers are not defined or
described in a particularly meaningful way
through a single category or description
(Freemont, 2003). School refusal behavior covers
a wide spectrum on a continuum. This
classification includes those who attend school
but are under extreme psychological duress and
stress, those who display repeated misbehavior in
the mornings to avoid school, children who are
chronically late for school, those with episodic or
repeated absences, and those who are
completely absent for long periods of time. These
children and their behaviors may share little in
common other than a motivation to avoid
attending school. The refusal or avoidance of
school is often the only common characteristic.
Kearney (2008b) has stated that - as a group - school refusers are non-homogeneous, and the classification or
designation as a “school refuser” is rendered almost meaningless due to the broad spectrum of behaviors and
motivations. Any attempt to intervene with these children in a “one size fits all” approach is likely to be doomed from
the start. The behaviors themselves, the underlying causes, and the factors that reinforce school refusal behavior vary
widely from individual to individual. The variability calls for an approach different from traditional approaches to
behavioral change.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 8 of 48
Most behavioral difficulties are traditionally approached from a categorical model that is geared toward separating
phenomena (observed behavior) into discrete categories. This is the underlying basis of the Medical Model and the basis
for the Diagnostic and Statistical Manual of Mental Disorders –TR-IV (2000). Albano et al., (2003) indicated that the DSM
system represents the categorical classification approach, attempting to separate disorders into clinically derived and
mutually exclusive classes based upon a hierarchical model. The categorical approach as espoused by Kennedy, (1965)
and Coolidge et al., (1957) assumed that school refusal behavior can be viewed as relatively separate phenomena. At the
core are symptoms that distinguish the presence or absence of a disorder. Unfortunately, the enormous variability in
school refusers makes it difficult to derive any meaningful categories or symptoms that reflect the complexity of the
phenomenon.
A categorical approach to school refusal does allow us to attempt to develop descriptors of the behavior and thereby
differentiate between those who meet criteria for school refusal and those who do not, but these differentiations are
not particularly meaningful. A categorical approach to school refusal also runs the risk of inappropriately classifying or
diagnosing an individual as a “school refuser” when there may be more significant issues existing. Also, a categorical
approach runs the risk of the negative labeling that so often occurs once someone has been identified as “abnormal” or
as differing from the population as a whole. Many times this negative labeling can lead to inappropriate functioning or a
self-fulfilling prophesy.
Another typical approach for dealing with individuals whose behavior is outside the norm, which attempts to avoid the
negative aspects of a categorical model, is a dimensional approach. Dimensional models like that proposed by
Achenbach (1991) view behavior on a continuum and are only concerned with behaviors that create dysfunction or a
lack of appropriate adaptation. The continuum views behavior on a scale from adaptive to dysfunctional or from absent
to severe. Unfortunately, with school refusal, delineating behavior on a continuum does not particularly provide any
insight as to the nature of the phenomenon or lead to reasonable interventions.
A more appropriate model for working with individuals who are school refusers might be to view the school refusal
behavior through a Functional Model. A Functional Model looks at the purpose the behavior serves and what motivates
or maintains the behavior (Kearney, 2001 and Kearney and Albano, 2007).
A Functional Model of School Refusal Behavior
(Kearney, 2001 and Kearney & Albano, 2000 & 2007)
All human behavior is purposeful. By understanding the function or purpose of a child’s school refusal, we can increase
the likelihood of effectively intervening. In addition, all behavior that is not reinforced extinguishes over time. For school
refusal, understanding the underlying factors that maintain or reinforce the behavior will be a key in making the
therapeutic changes necessary for an effective intervention. Kearney and Albano (2007) advocated a functional analysis
of the problem behaviors on both a descriptive level (soliciting information from the child and parents through
interviewing and rating scales) and an experimental level (involving direct observation of the school refusal behavior).
This analysis can form a synthesis to determine which intervention approaches are most likely to be successful. While
school refusal behavior can take many different forms and occur in varying degrees of severity, the functions or reasons
behind the behaviors are relatively few. They can be grouped as an attempt to either:
•
Avoid negative experiences associated with school
1) Avoidance of stimuli that provoke a sense of general negative affect
2) Escape from aversive social or evaluative situations
•
Pursue positive experiences by not attending school
3) Attention-seeking behaviors
4) Tangible reinforcement outside the school
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 9 of 48
Children who are refusing school in order to avoid negative experiences may be attempting to avoid a particular
stimulus or series of stimuli related to school attendance that ultimately result in a negative experience. The stimuli to
be avoided may involve something specific like a bully, or more pervasive like the structure and discipline of the school
setting. Other school refusers may be attempting to escape from the negative social or evaluative aspects of attending
school. Some school refusing children may be pursuing a positive experience through refusing school, such as tangible
reinforcers like staying at home, gaining attention, or engaging in more desirable activities.
Kearney (2007a) speculated that as many as one-third of school refusers may do so for multiple functions or purposes.
For example, some children may initially refuse school to avoid the negative experience of an overly punitive teacher. If
they are successful in remaining at home, they may realize the desirability of remaining at home and then refuse school
for both positive experiences and avoidance of negative experiences. Children who refuse school for multiple reasons
may require more sophisticated intervention strategies combining multiple approaches.
The Functional Model of school refusal recognizes these fundamental distinctions and
approaches behavior change on the basis of these different purposes and motivations.
Dube and Orpinas (2009) found that in a sample of upper elementary school refusers,
17.2% had a multiple profile which included elements of several purposes, and 60.6%
were refusing to attend school from a primary motivation of attention seeking.
Relevant research validating the approach of a Functional Model includes uncontrolled
work as well as controlled studies of prescriptive and non-prescriptive treatment (Chorpita et al., 1996; Kearney, 2002a;
Kearney, Pursell, & Alvarez, 2001; Kearney & Silverman, 1990, 1999). Recent data support the use of a Functional Model
of school refusal behavior. Among a sample of 222 youths with school refusal behaviors, Kearney (2007b) demonstrated
that utilizing structural modeling to identify the function of school refusal was a better predictor of school absenteeism
than traditional measures of fear, anxiety, and depression.
Silverman et al. (2008) concluded that sufficient information is available to include this form of prescriptive treatment as
fitting the criteria as a Possibly Efficacious Treatment Approach for school refusal. To gain a fuller understanding of the
different functions that school refusal might serve, each of the four functions will be reviewed in detail.
Function 1: School Refusal for Avoidance of Stimuli That Provoke a Sense of General Negative Affect (SPNA)
For many school refusers, specific stimuli or situations (e.g., bus ride, lunchroom, fire alarm, animal in classroom,
restrooms, etc.) produce negative or uncomfortable feelings about school, which the child feels he or she must avoid.
Some children may not be able to identify the specific fear-related stimuli. This may not be resistance, but can be due to
a lack of specificity or an inability to conceptualize and verbalize what is making them uncomfortable about school.
What they are very clear about is they “don’t want to be at school” and that “being at school makes me feel yucky.”
Kearney (2008a) has indicated that the child’s distress about attending school has multiple dimensions, including
physical, cognitive, and behavioral components. The physical component may include shakiness, nausea, headaches, and
muscle pain, etc. The distress or general negative affect also contains a cognitive or thinking component, which can
create ongoing questioning or self-statements about going to school or verbal pleas regarding school attendance. A
behavioral component may include overt symptoms such as crying, tantrums, withdrawal, distractibility, and irritability.
Many of the children in this grouping (SPNA), score higher on measures of general anxiety and on symptoms of
depression. These children do not display problematic behaviors otherwise and tend to be lower on attention problems,
delinquency, or aggressive behaviors. They characteristically tend to be more dependent than their peers are, although
they come from generally healthy families. Diagnostically, they may be characterized as having generalized anxiety
disorder (GAD), depression/dysthymia, separation anxiety disorder, social phobia, and specific Phobias. In addition, this
group engages in significant somatization as an attempt to avoid the negative stimuli associated with school (Kearney,
2001).
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Function 2: School Refusal to Escape from Aversive Social or Evaluative Situations (EASE)
For another group of school refusers, school is a particularly negative and punitive experience due to the social or the
evaluative aspects of the school setting. For these individuals, school is the place in their life where they experience
significant embarrassment, shame, ridicule, rejection, debasement, and even abuse from their peers or from school
personnel. These school refusers may literally lack the capacity for measuring up to the expectations for academic
progress and learning and are constantly receiving “a negative evaluation.” For this group, school is where they are
constantly reminded that they are not good enough, smart enough, quick enough, and talented enough to achieve at a
normal level, let alone, excel.
Many of these school refusers (EASE), struggle with common
situations that naturally occur in the social and evaluative setting
we call public education. Common examples of social situations
that are difficult for these youth might include interactions with
peers in the hallways, “free form” or unstructured situations,
attending assemblies, group work, talking in class, extracurricular
activities, starting or maintaining conversations, or working on
projects with other students. Common performance situations that
these youth may struggle with could include speaking before class,
writing on the board, being called on in class, tests or graded
situations, performance classes (i.e. physical education, music,
etc.), eating publicly, or taking tests and receiving graded results.
For these youth school refusal might be motivated by a desire to avoid certain people (teachers or peers) due to past
embarrassment, shame, or ridicule. This type of school refuser may typically be a child who struggles to perform up to
expectations or who has real difficulty fitting in with the other children. Kearney and Albano (2000) reported that this
particular group may have higher scores on measures of general anxiety, score higher on symptoms of depression,
experience higher levels of social anxiety, and display significant levels of withdrawal and somatization. Many of these
school refusers come out of situations and settings of physical or social isolation. They may also experience significant
family and community detachment. This lack of a social experience base makes interacting with others in a school
setting particularly troublesome, awkward, and difficult. The lack of experience leads to poor social interactions and
greater anxiety about the social aspects of school.
Kearney (2008a) has found that these youth (EASE) tend to be somewhat older (11-17) than those who avoid school to
avoid a negative affect (SPNA). Cognitively they are more mature and can point to specific situations that cause their
distress. This social and evaluative anxiety overlaps with the natural egocentrism of adolescence, and - when intensified
- may result in school refusal behaviors. These youth may “skip” particular classes, ask for frequent schedule changes,
avoid entering the building until the last minute to limit social contact, shy away from speaking to classmates or
teachers, or completely stay away from situations in which large numbers of students are present. Diagnostically these
youth are frequently classified as having generalized anxiety disorder (GAD), social phobia, depression/dysthymia, or a
premorbid avoidant personality disorder (Kearney, 2005).
Function 3: School Refusal for Attention-Seeking Behavior (ASB)
For some school refusers, the refusal behavior is motivated by a desire to gain something positive rather than avoiding a
negative that comes with attendance. They may be seeking positive rewards for non-attendance, including intangibles
such as attention or sympathy. The child seeking attention may have little distress about school-related items or
situations. In fact, they often attend school easily and smoothly as long as a parent or older sibling is allowed to attend
with them. If the parent or sibling is not allowed to attend, their behavior is usually geared toward going home or going
to a parent’s workplace.
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Kearney and Albano (2007) reported that the in-school behavior of these youths (ASB) includes noncompliance,
defiance, tantrums, manipulations, or oppositional behaviors. These behaviors may not be limited to school, but may be
displayed in a proactive fashion at home to avoid separation and prevent going to school. The attention-seeking school
refuser may engage in various morning misbehaviors to avoid school and stay at home, while simultaneously increasing
the likelihood of attention (tantrums, clinging, locking themselves in their room, exaggerated physical symptoms,
noncompliance, running away, etc.). On some level they understand that not going to school assists them in obtaining
the positive experience of attention and staying at home. In order to get the attention and sympathy that necessarily
comes with their refusal to attend school, these youth may exaggerate physical or emotional symptoms. Complaints
may include a variety of vague physical symptoms such as headaches, stomachaches, back pain, etc. for which no
organic basis can be found. Some may even go to the extent of “playing dead” as a method of avoiding school
attendance.
The attendance patterns of these attention-seeking youth may show a great number of “tardies,” frequent requests to
go home early, frequent time spent in the nurse’s office, or badgering teachers to let them go home. While many of
them experience comorbid separation anxiety, not all youth whose behavior serves this function have significant issues
with separation anxiety. In a larger sense their behavior may be more manipulative, intended to obtain parental or
school personnel attention. Many youth who naturally experience some degree of separation anxiety about going to
school may exaggerate this discomfort to manipulate, control, or solicit attention. Kearney (2001) reported that for this
group, “separation anxiety” may need to be viewed as one of three types:
1) Children who are truly anxious when separated from caregivers
2) Children who are more broadly seeking general attention
3) Children who are both anxious about separation and also seeking attention
These school refusers (ASB) tend to be younger (mean age 9.6) and are from families with very low levels of
independence and autonomous functioning (enmeshed). Frequently, there is a long history of acquiescence to the
child’s wishes or demands that has been achieved through emotional terrorism or manipulation on the child’s part.
Diagnostically, these school refusers tend to struggle with separation anxiety disorder, generalized anxiety disorder
(GAD), and oppositional defiant disorder (Kearney, 2001)
Function 4: School Refusal for Tangible Reinforcers Outside of School (TROS)
For another group of school refusers, the function served by the refusal
seems to be to allow them to pursue experiences that are perceived as being
more rewarding than attending school. By not going to school, these youth
may be pursuing a variety of tangible reinforcers they can only attain by not
going to school. Often the refusal is an attempt to pursue reinforcers that are
particularly pleasing and powerful, such as sleep, TV, video games, internet,
friends, day parties, the mall, etc. For these youth (TROS), their school refusal
is less anxiety-based and more a result of impulsivity or an inability to delay
gratification. Their school refusal may be evolving into a more truant dynamic
with very little distress about attending school, but distress about not
attaining a rewarding experience (Kearney, 2001).
Typically these youth have lower levels of anxiety, depression, or distress
about going to school. “I could go to school; no big deal; but I’m not; and you can’t make me.” These youth are generally
older and display more attention problems, delinquent behaviors, and aggressiveness. Families are more conflicted and
have low levels of cohesion. Communication between parent and child is typically non-functional or non-existent.
Diagnostically, these youth experience generalized anxiety disorder (GAD), oppositional defiant disorder, conduct
disorder, and depression/dysthymia (Kearney and Albano, 2007).
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Function 5: Multiple Functions
In some situations, a youth’s school refusal behavior may simultaneously serve more than one function. Kearney and
Albano (2007) reported that “some children, perhaps as many as a third, refuse school for two or more reasons.” In
other circumstances, the purpose or function of the original school refusal behaviors can morph over time to serve a
different purpose or function. A common example is a child who is so distressed about stimuli at school that produce
negative affect, that he begs his parents to let him remain at home (SPNA). Once at home, a secondary positive
experience of parental attention (ASB) or the possibility of pursuing tangible rewards (TROS), internet, TV, special meals,
etc. may take over as the primary motivation and ultimately become the driving force behind the school refusal.
Another example might be the child who has been out of school for a long period of time due to attention seeking
behaviors (ASB), and then becomes anxious and overwhelmed at the prospect of having to return to a great deal of
make-up work or to have to interact with new teachers and peers. Not surprisingly, youth who refuse school for multiple
reasons or functions are likely to require more complex interventions. Likewise, youth who have missed school for a
longer period of time will require a more complex intervention than a child who has just started to refuse school.
Underlying Psychological Disorders and Comorbid Conditions
While a functional model of school refusal allows us to identify the purpose that the school refusal serves, we cannot
simply stop there. The first analytical or diagnostic decision is to identify the purpose or function of the school refusal,
but that is not sufficient to effectively intervene. This point may be best illustrated by a case example.
Bob and Bill are both refusing school as an attempt to avoid the social and evaluative components of school. In both
situations, it is clear and they can articulate that they “just don’t fit in.” Bob, in addition to his school refusal has an IQ of
155, is an Olympic class gymnast, has won awards for creative writing, and has very supportive and understanding
parents. Bill also refuses school for the same purpose of avoiding the social aspects of attendance, but has an IQ of 80,
has a significant reading disability, is periodically enuretic, and has consistently received failing grades. His father is in jail
and his mother has a significant substance abuse problem.
In both situations, the school refusal serves the function of avoidance or escape from the social or evaluative component
of school attendance. A “one size fits all” approach to Bob’s and Bill’s school refusal, even one based on a thorough
understanding of the purpose and function of the refusal behavior, is unlikely to be successful without a second
analytical or diagnostic analysis. This second process must identify any underlying psychological disorders or comorbid
conditions that may be creating, exacerbating, or impacting the school refusal behaviors. The purpose of this secondlevel analysis is to identify any psychopathology or serious emotional issues that might be causing or contributing to the
school refusal. In many instances, it may be necessary to address the underlying conditions before any substantive
progress can be made on dealing with the school refusal itself.
Separation Anxiety Disorder
One frequently observed underlying condition associated with school refusal is separation anxiety disorder. The DSM-IVTR (2000) describes separation anxiety disorder as a condition occurring prior to age 18 in which the individual becomes
excessively anxious when separated from parents or home. Symptoms of anxiety must have occurred for a period of at
least four weeks. Often the child displays excessive worries, fears, distress, nightmares, and obsessive thinking about
being separated from home or primary caregivers. The reaction is excessive, and any anticipated separation may
produce somatic complaints. Onset of separation anxiety occurs normally during preschool years and occurs in
approximately 4% of all children. The disorder is more common among first-degree relatives and in children of parents
with panic disorder. A level of separation anxiety is normal for children between 18 months and 3 years, but by age 4,
most children do not continue to show symptoms. About 4% of children continue beyond age four, and only 1%
continue to be symptomatic by ages 14-16 (DSM-IV-TR, 2000).
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Many of these youth are excessively miserable when not with loved ones, preoccupied with fears about health and
safety of parents, and avoid going places on their own. Children dealing with excessive separation anxiety may be
reluctant or refuse to participate in sleepovers, demand that someone stay with them at bedtime or sleep with them,
and/or may experience recurring nightmares about being separated from parents. This can be a significant part of school
refusal behaviors as a logical extension of their already dysfunctional anxiety level. When forced to separate from
parents in order to attend school, these youth may become preoccupied with their parents’ whereabouts, prompting
requests for unnecessary phone contact. They can also be so threatened and preoccupied about being separated from
their parents that they are unable to perform at an acceptable level in the classroom. The child who is obsessing about
the idea that his mother might have an accident on the way home is unlikely to be able to attend to class work, and as
the separation anxiety builds, it may prompt an upset stomach, headache and other maladies, disruptive behavior, or
pleas to make a phone call.
Children who suffer from separation anxiety disorder may also engage in disruptive behaviors for the purpose of forcing
parental contact. They frequently create situations in the morning at home that may delay going to school or prevent
attendance entirely. Part of the symptom repertoire can include the display of a number of vague somatic symptoms.
These children may have frequent complaints of dizziness, nausea, cramps, vomiting, palpitations, etc., even to the point
that symptoms are inconsistent or physically impossible, i.e. “I feel sick at my stomach, but I’m starving to death.
Generalized Anxiety Disorder (Overanxious Disorder of Childhood)
Many youth who refuse to attend school also struggle with generalized anxiety disorder (GAD) as identified in the DSMIV-TR (2000). Although they do not experience episodes of acute panic, these individuals feel tense or anxious most of
the time and find it difficult to control their worries. Their uncontrollable worry may relate to school attendance or be
less specific and more generally pervasive. Criteria for GAD include the requirements that the condition has persisted for
more than six months and that the individual experiences less specific bodily symptoms than other anxiety disorders.
Symptoms may involve restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances.
It includes what had formerly been called the overanxious disorder of childhood. For many children and adolescents,
anxieties typically involve non-specific issues around competence, performance, catastrophic events, perfectionism, and
lack of approval.
Youth with GAD may worry excessively about their ability to perform satisfactorily at school. This excessive worry and
discomfort may result in a number of escape or avoidance behaviors. Some children may be excessively focused on
perfection to the point at which they cannot adequately conform to the expectations of the classroom. Their concern
about perfectionism may result in requiring excessive time or effort to complete basic assignments. School becomes a
place where they are frequently reminded of their inability to achieve perfection and is viewed as a source of frustration
and failure, which should be avoided at all costs. If the generalized anxiety is untreated, it is unlikely that the child will
ever develop sufficient comfort with the school experience to attend regularly.
Specific Phobia (formerly Simple Phobia)
Individuals with specific phobias fear particular objects or situations (e.g. animals, storms, closed spaces) and react
excessively and disproportionately to the phobic object or situation. DSM-IV-TR (2000) criteria specify that the person
often recognizes the fear as unreasonable, but still avoids the specific stimuli, or endures it only with intense distress.
For children it must be of at least six months duration. Some youth may not recognize their fear as excessive and may
express it non-verbally through crying, tantrums, freezing, or clinging. Specific fears in children are fairly normal, but in
most situations, the fears fade with development or gradual exposure to the feared situation or object. A phobic
reaction to the stimuli of “school” as a generic concept is frequently observed, but it is important to differentiate among
specific phobia (germs, an animal in the classroom) social phobia (no one there likes me and they make fun of me), and
separation anxiety (separation from a “safe person,” place, or object). Also, realistic childhood fears are developmentally
appropriate, so a distinction must be made based on the extent to which the specific phobia interferes with functioning
and the length of time the phobia has persisted.
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Social Phobia (Social Anxiety Disorder)
Many school refusers have significant issues with social phobia or a social anxiety disorder (Kearney, 2005). These
individuals fear embarrassment or humiliation in social or performance situations. The individual recognizes that the
fear is excessive and that it interferes with normal functioning. In children, there must be evidence of the capacity for
age-appropriate social relationships and the anxiety must occur in peer settings, not just with adults. Children do not
always recognize that their fear is excessive, and the anxiety may be expressed non-verbally through crying, tantrums,
and freezing or shrinking from unfamiliar people. Some consideration must be given to 1) the level of social exposure
the child has had in the past and 2) whether or not the child has demonstrated the ability to interact appropriately with
individuals with whom they have greater familiarity and exposure (DSM-IV-TR, 2000).
Panic Attacks
A panic attack is a brief episode in which the individual feels intense dread, accompanied by a variety of extreme
physical symptoms. It begins suddenly and peaks rapidly. The onset of the attacks and the presence of “triggers” are
important. Three types of panic reactions are observed: 1) unexpected (e.g. panic disorder), 2) situationally bound (e.g.
phobias), and 3) situationally predisposed (e.g. PTSD). Panic disorders are rarely seen in children until late adolescence,
and the onset of panic disorder typically occurs in the 20s to 30s (DSM-IV-TR, 2000). In working with younger children,
they may experience “freak-outs” and “meltdowns,” but it would be rare for young children to experience the
physiological extremes which typically occur in adults with panic disorder. In older adolescents, particularly those with a
family history of panic disorder or panic attacks, some prodromal signs of a developing panic disorder may be observed.
Obsessive Compulsive Disorder (OCD)
Obsessive compulsive disorder (OCD) can create particular difficulties for some children who ultimately refuse school as
a way of managing their obsessive compulsive rituals and thinking. Individuals with OCD are bothered by repeated
thoughts and behaviors which seem senseless, even to them, but
somehow make them feel less anxious and more comfortable (DSM-IVTR, 2000). This recognition of the excessiveness or unreasonableness
does not always occur with children. If the school setting blocks or
makes it extremely difficult for the child to engage in their anxietyreducing rituals, school may be avoided or refused. While the obsessions
(thoughts or images) cause distress, the compulsions (actions) prevent,
reduce, or relieve anxiety. OCD may take the form of either obsessions
or compulsions, but normally both are present. Washing, checking,
counting, and ordering rituals are particularly common with children.
The relationship between school refusal and OCD is readily seen in the
following example.
Megan was diagnosed at a relatively young age with obsessive
compulsive disorder. As an adolescent she has found ways of concealing
many of her compulsions in ways that are more socially acceptable.
However, one set of compulsive behaviors that she has not been able to
give up or conceal is her need to have her appearance absolutely perfect
before she can leave for school. This often results in dressing and
redressing multiple times to the point that she misses the bus, is late for
school, or completely shuts down and refuses to go to school, because
she “can’t get her hair to look right.” Until the OCD is addressed through behavior modification, medication, or both - it is unlikely that
the school refusal behaviors can be addressed successfully.
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Post Traumatic Stress Disorder (PTSD)
Many children who are school refusers have suffered significant trauma at school or in the school context. The child who
has been assaulted at school, the child who was humiliated by classmates or teachers, the child who was sexually
abused at school, the child who was verbally or emotionally abused by a teacher may be experiencing post traumatic
stress disorder or PTSD. Post traumatic stress disorder is observed in individuals who have experienced, witnessed, or
been confronted with an event involving threat of death, serious injury, or loss of physical integrity (sexual abuse). The
person’s response to the event involved fear, helplessness, or horror, and these individuals continue to experience the
fear and anxiety in a repetitive fashion when triggered by similar stimuli or stimuli reminiscent of the original trauma
(DSM-IV-TR, 2000).
In children, PTSD is often expressed by disorganized or agitated behavior. The youth re-experiences the trauma, avoids
stimuli (or is unresponsive to stimuli) associated with the trauma, and experiences a level of increased arousal. Themes
or aspects of the trauma may be expressed in the play of traumatized children. There may be frightening dreams
without recognizable content, or trauma-specific reenactment may occur (DSM-IV-TR, 2000). While the school setting
may be the source of the original trauma, we continue to expect and require the child to attend school and run the risk
of being further traumatized. As the trauma response becomes intensified, the child may refuse school as a coping
mechanism.
Children may have been exposed to violence, assaults, threats, intimidation, and physical or sexual abuse in the school
setting or in the school buildings or on school grounds. If not directly exposed, the media may have exposed them by
coverage of school violence to the point at which the child actually perceives a legitimate threat to her life and safety by
being in the school building. Until the PTSD symptoms have been resolved, requiring the child to attend school may lead
to additional traumatization and increased avoidance behaviors.
Major Depressive Episode
Depression, and the accompanying loss of energy and anhedonia, may make attending school very difficult for many
children. Issues of sleep irregularities, loss of appetite or increased appetite, and difficulties with concentration are an
integral part of a major depressive episode, and may ultimately result in a child’s inability to attend school. In children, a
major depressive episode is more likely to occur in conjunction with other disorders (oppositional defiant, conduct
disorder, ADHD, and anxiety Disorders) than in isolation, making attending school on a regular basis extremely difficult.
Major depression is less common in children than in adults, particularly prepubertal children, but has generally been
under diagnosed in children (DSM-IV-TR, 2000). In children, the affective state may be an irritable, “agitated depression”
rather than the depressed mood or loss of interest in activities typically observed in depressed adults.
Some children may lack sufficient capacity for selfreflection and self-observation to be able to identify
their affective state as depression. A concept of time
or the future that is not yet fully developed may also
make identification of what they are experiencing
difficult. Many children may have a family history
replete with individuals who have experienced
significant major depressive episodes. In such cases, it
is very likely that they may be experiencing prodromal
physical and neurological symptoms of depression
without being capable of accurately labeling them.
These prodromal symptoms may make school
attendance very difficult and can ultimately result in
school refusal.
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Oppositional Defiant Disorder (ODD)
Oppositional defiant disorder (ODD) may be the underlying cause in many instances of school refusal. The refusal to be
compliant with the wishes and direction of adults is the hallmark of ODD. What more direct and age-appropriate manner
of expressing noncompliance and opposition to adult wishes than to refuse to attend school? Children with ODD often
display multiple examples of negativistic, defiant, disobedient, and hostile behaviors that have been occurring for a
period of more than six months. This can often be seen in very young children, but should be diagnosed with the
recognition of normal developmental oppositionalism (DSM-IV-TR, 2000). Onset is typically gradual, occurring over the
course of months or years. It is frequently observed in the children of families with serious marital discord, substance
abuse, or a primary caretaker who struggles with depression.
Conduct Disorder (CD)
Children who refuse school initially as a product of their ODD may continue to develop more significant behavioral
issues, which may ultimately reach the level of a conduct disorder (DSM-IV-TR, 2000). In many situations, there is a fairly
predictable progression from ODD to CD to antisocial personality disorder (ASPD). Conduct disordered children typically
violate the rights of others, particularly in terms of aggression, destruction of property, lying, stealing, and serious rules
violations.
The repetitive and persistent nature of the behavior distinguishes it from an adjustment disorder. This disorder involves
aggression, destructiveness, deceit, or theft, and violation of rules and expectations. One of the specific diagnostic
criteria for CD is a failure to attend school “often truant from school, beginning before age 13 years” (DSM-TR-IV, 2000).
Almost all cases that meet the criteria for CD would also meet criteria for ODD. However, the converse is not necessarily
true.
Encopresis and Enuresis
For a child who struggles with enuresis and encopresis, the thought of attending school and having an “accident” in a
public setting can create sufficient anxiety to make attending school very difficult. A child may refuse to attend school as
a safe way of avoiding embarrassment, shame, and ridicule. The anticipatory anxiety that comes with even the thought
of being unable to successfully regulate bowel and bladder in school may actually increase the possibility of the loss of
bowel or bladder control. School refusers may be opting out of school rather than run the risk of an embarrassing event.
Attention Deficit Hyperactivity Disorder (ADHD)
For a child with attention deficit hyperactivity disorder (ADHD), attending school might be considered “cruel and unusual
punishment.” For the entire school day, the child will be asked to comply in ways they find difficult, if not impossible.
They will be subject to ongoing correction, criticism, critique, and negative messages about them, their behavior, and
their performance. It would stand to reason that some of these children may “opt out” and either refuse to attend
school completely or be unable or unwilling to participate in the educational processes for an entire day and engage in
some form of escape behaviors, such as school refusal.
ADHD has had a variety of names and descriptions since it was first described in 1902 and is one of the most commonly
diagnosed disorders of childhood (DSM-IV-TR, 2000). It is a composite disorder including two major symptoms:
inattention and impulsivity/hyperactivity. It is especially difficult to establish this diagnosis in children younger than four,
although symptoms can be observed. Younger children typically experience few demands for sustained attention until
the school setting. Criteria call for symptoms to have occurred prior to age seven and for symptoms to occur in two or
more settings and not exclusively at school. Mothers of children with ADHD frequently report higher intrauterine
activity, excessive crying, sleep issues, and increased irritability (DSM-IV-TR, 2000).
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Developmental milestones occur early, and these children “hit the ground running.” They appear to be “motor-driven”
and often engage in daredevil and risky activities. They may perform poorly in school, though IQ is typically in the
normal range. There is a significant correlation between first degree family members and individuals diagnosed with
ADHD. A family history of mood disorders, learning disabilities, substance abuse, and antisocial behavior is often
observed. DSM-IV-TR (2000) identifies four specific types of ADHD:
1) Attention Deficit/Hyperactivity Disorder, Combined Type, in which the criteria for both inattention and
hyperactivity/impulsivity are met
2) Attention Deficit/Hyperactivity Disorder, Predominantly Inattentive Type, in which the criteria for inattention
but not hyperactivity/impulsivity are met
3) Attention Deficit/Hyperactivity Disorder, Predominantly Hyperactive/Impulsive Type, in which the criteria for
hyperactivity/impulsivity but not inattention are met
4) Attention Deficit/Hyperactivity Disorder Not Otherwise Specified, in which there are prominent atypical
symptoms of inattention or hyperactivity/impulsivity.
Learning Disorders
A significant comorbid condition, which directly impacts school refusal behavior, is the presence of a lLearning disorder.
Learning disorders are characterized by inadequate development of academic skills that are not due to demonstrable
physical or neurological disorders. Criteria for a learning disorder as outlined in the DSM-IV-TR (2000), requires that
academic achievement be substantially below what would be expected given the person’s age, IQ, and educational level.
Estimates are that between 2% and 10% of the population meet the criteria and approximately 5% of students in public
schools are identified as having a learning disorder. Attending school is likely to be extremely frustrating for these youth
as they may not be able to meet or measure up to the expectations for normal achievement and academic progress.
Many of these youth are labeled or targeted for ridicule by their peers who are well aware that the child is not
progressing academically. Many children with learning disabilities avoid the negative experiences of school, which are
almost inevitable for them, by refusing to attend or other negative and self-defeating coping strategies.
Diagnostic and Assessment Issues of School Refusers
In addition to the diagnosable comorbid conditions discussed thus far, many school refusers have a variety of underlying
conditions that may cause, exacerbate, or reinforce refusal to attend school. These individual characteristics,
environmental factors, or extenuating circumstances must be identified and successfully addressed in order to complete
a successful intervention and to prevent relapses from occurring (Kearney & Albano, 2007). Absent a clear identification
of all underlying conditions, many interventions with a school refusing youth are doomed to have limited success or will
succeed for only a limited time before the child adopts other, alternative means of avoiding school attendance.
Medical Examination
Due to the significant somatization that many of these children display, it is essential to
obtain a complete medical history and a thorough physical examination. While many of
the school refuser’s somatic symptoms are indications of malingering or psychosomatic
in nature, some children may be experiencing significant physical symptoms or
organically based difficulties. A child who has had no real issues with attending school,
but who suddenly sleeps constantly, lacks energy, has a variety of physical complaints,
aches, and pains may be malingering or developing psychosomatic illnesses to justify his
or her failure to attend. The same set of physical symptoms being observed may also be a behavioral description of a
child suffering from mononucleosis. Thyroid conditions, diabetes, lead/mercury exposure, anemia, and seizures are all
physical disorders that can result in the inability to attend school physically.
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Separate Interviews
It is also critical to conduct separate interviews with parents and the child (Kearney and Albano, 2007). Many of these
children come from extremely enmeshed families and often there exists a version of “unispeak,” in which the parent
speaks for the child or the child speaks for the parents. Conducting a separate interview with the child and parents
allows for greater insight into the actual behavior that is taking place. Kearney and Albano (2007) suggested that “as a
general rule in cases of school refusal behavior, interview the child before the parents.” They also provided a structured
set of questions for the child and parent to answer separately, which may provide some insight into the nature and
purpose of the school refusal.
Secondary Gains
Part of the assessment process is an attempt to identify the purpose of the school refusal (functional model), but in
addition, there must be a clear understanding and evaluation of other factors maintaining school refusal behaviors. In
order for the behavior to continue to persist, there must be a reinforcing contingency at work. Any intervention strategy
must address the reinforcers of inappropriate behavior. Uncovering any secondary gains that are produced by school
refusal and determining when and how they occur are essential to developing an effective intervention plan and
preventing relapses.
Anxiety/Depression
For many children who refuse school, a strong underlying component of the refusal is
anxiety and depression (Last & Strauss, 1990). School refusal may be an extended
symptom of underlying anxiety or depression and must always be considered when
performing the assessment. Many of these children have such strong underlying
anxiety issues that the nature of the chaos, confusion, and excitement of a normal
school day may create sensory overloading which mounts to an intolerable level of
stress. It would not be unusual for them to arrive at school each day and find that the
anxiety builds and builds as the day progresses until it reaches a point of critical mass.
At the point when the anxiety becomes unbearable, the child then resorts to some
form of escape or avoidance behaviors. Such behaviors may result in going home or
spending the day in the health room or nurse’s office.
Family Functioning
In addition, for many school refusers, a pattern of family dysfunction may be creating or exacerbating the school refusal
behavior. Some parents may be active participants in encouraging school refusal behaviors to meet their own individual
needs or the needs of the family. Others, while not consciously encouraging school refusal, may be collaborators in
avoidance of attending school (Kearney & Silverman, 1995). It would, however, be faulty to assume that all school
refusers come from dysfunctional families. Many school refusers have families that are perfectly healthy and functional,
but there may be specific stimuli about the school experience that produce inappropriate coping strategies.
Patterns of School Absence
In assessing school refusers it is important to note any particular pattern of school absence. The child who consistently
misses school on Thursdays may be communicating that some event or person is only experienced on that particular
day. It could be gym class, art class, or contact with a bully, which only occurs on Thursdays. A careful review may
provide information about the precise intervention that is required. In addition, it would also be important to carefully
review the time period of the first onset of the problem. Answers to the proverbial “Why here? Why now?” questions
may provide significant information required for a successful intervention.
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Contextual Issues
Kearney (2008b) identified a number of contextual issues that have to be considered when attempting to intervene with
a child who is a school refuser, including homelessness and poverty, teenage pregnancy, school violence, school bullying,
and school climate. He defines school climate as “the student’s feelings of connectedness to the school and the degree
of support of their academic and other needs.” School climate is the match or “goodness of fit” between the student’s
unique academic needs and interests and the curriculum and educational programs. A poor match may create a climate
in which school refusal exists and will continue to persist without appropriate modifications or a better match. Kearney
(2008b) states that “this is especially important for youths with learning problems, who are at special risk for school
refusal behaviors.”
Standardized Measures
Obtaining collateral information from other people who know or have interactions with the child may also provide a
direction as to the purpose of the school refusal and the factors that reinforce or support the behavior. Standardized
measures that assess functioning levels and underlying conditions may also be a key supplement to existing information.
Standardized measures that evaluate the level of anxiety or level of depression a child is experiencing will put any
intervention plan on a much firmer footing and guarantee a higher success rate when intervening with school refusers.
Some of the more commonly used standardized measures are:
 Social Anxiety Scale for Children/Adolescents - assesses fear of negative evaluation and social avoidance and
distress.
 Child Behavior Checklist (Achenbach) - Children who refuse school to escape aversive social or evaluative situations
show significantly higher scores on Withdrawal and Somatic Complaints Scales, as well as the overall Internalizing
Scale.
 Behavioral Assessment System for Children (BASC) - provides a measure of Internalizing vs. Externalizing problems as
they relate to school refusal.
 State-Trait Anxiety Inventory for Children - a 40-item inventory which distinguishes situational based anxiety from
characterological anxiety.
 Manifest Anxiety Scale - a 37-item, yes/no inventory which targets physiological anxiety, worry, and concentration
difficulties. It is useful for children who refuse school to avoid negative situations (escape behaviors).
 Reynolds Child/Adolescent Depression Scale - measures depressive symptoms and is particularly useful for children
who refuse school to avoid general negative affectivity or to escape evaluative situations.
 Anxiety Disorders Interview Schedule for the DSM-IV-TR - offers a parent and child version and a special section on
school refusal related problems.
 School Refusal Assessment Scale - features Parent and Child Questionnaires to determine the function of the school
refusal behavior (Graywind Publications).
Strategic Intervention Planning
Strategic Intervention with school refusers must be based on decisions and information arrived at during the assessment
and diagnostic process. Intervention plans should describe outcomes you wish to achieve and the interventions you plan
to use to reduce, relieve, ameliorate, or change the symptoms (distress) or impairment (loss of functioning). By asking
yourself “what” questions about the individual, you can determine the goals of the intervention. (e.g. What is the most
distressing aspect of the school refusal? What physical factors may contribute to the situation or exacerbate the refusal?
What stressor is the individual experiencing? What underlying conditions must be addressed? etc.) The objectives of the
intervention plan specify the “how” goals are to be addressed and the interventions that will be attempted. (e.g. How
can attendance be increased? How will the learning disability be addressed? How will the client learn to express anger
effectively? How will marital tension be reduced? How will family and teachers monitor change? etc.)
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Establishing a strategic intervention plan for a child who is refusing to go to school is critical, due to the fact that school
refusal behavior is not a single-factor disorder or syndrome, but takes various shapes and forms and serves different
purposes and outcomes. School refusers, as a group, are one of the most non-homogeneous groups of individuals who
share a common label. Any effective intervention must be based on a thorough assessment of the purpose of the
behavior, identifying any underlying or comorbid conditions, and targeting any factors that maintain, exacerbate, or
reinforce the school refusal behavior. An effective, individualized intervention plan is a four-step process: 1) identifying
the purpose that the school refusal serves, 2) identifying underlying or comorbid conditions, 3) establishing tentative
goals to be accomplished to successfully intervene, and 4) creating objectives that will lead to the accomplishment of
the intervention goals. An example of a Strategic Intervention Plan for a child engaging in school refusal behavior
follows:
Sample Strategic Intervention Plan for a School Refusing Child Diagnosed with Separation Anxiety
Type of School Refusal: School Refusal for Attention Seeking (AS)
Underlying or Comorbid Conditions: 309.21 Separation Anxiety, Early Onset, Possible Gastro-intestinal Concerns, and
Parental Conflict
Goal I: Decrease Excessive Anxiety Concerning Separation
Objective A: Explore precipitating events such as losses, stressors, and changes through individual therapy.
Objective B: Deal with issues related to rational fears through problem solving and teaching coping skills.
Objective C: Confront irrational fears and beliefs through cognitive therapy.
Objective D: Minimize the psychological impact of anxiety by teaching relaxation training and self-talk strategies.
Goal II: Increase School Attendance and Achievement
Objective A: Increase school and parent consistency through conducting joint meeting with parents, school personnel,
and child.
Objective B: Develop a “morning routine” which will be followed by the parents without regard to the child’s behavior.
Objective C: Develop a consistent and predictable strategy for assisting the child from the car to the classroom.
Objective D: Develop a system of “anxiety strategies” which can be deployed in the classroom to prevent withdrawal
through access to support personnel or “worry time.”
Goal III: Explore Physical Symptoms
Objective A: Conduct a complete physical to rule out any organic basis for vomiting or headaches.
Goal IV: Reduce Parental Conflict
Objective A: Parents will participate in marital therapy to learn effective strategies for conflict resolution.
Objective B: Educate parents regarding age-appropriate emotional separation through parenting classes.
Goal V: Increase Overall Level of Functioning
Objective A: Increase, through systematic desensitization, the amount of time the child can tolerate being away from the
parent.
Objective B: Use a family brainstorming process to develop a list of coping strategies that the child can employ to avoid
feeling anxious when separated.
Goal VI: Involve Other Family Members as Supports
Objective A: Increase anxiety-free time away from parents by utilizing his favorite Uncle to serve as a security object.
Objective B: Increase capacity to be away from parents through sleepovers at cousin’s house.
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Intervention Approaches
The treatment or intervention of choice with a school refuser is as early a return to school as possible (Kearney &
Silverman, 1999). The number one factor increasing the likelihood of success with children who can’t or won’t go to
school is an early return to the physical environment of school. Quickly returning to attending some portion of the
school day is the most effective intervention in almost all situations. The longer the child successfully remains outside
the school and outside a normal school day routine, the more difficult it will be to return to school. Identifying particular
classes the child can attend, identifying a limited time period during which the child is required to be in the building, or
identifying certain days on which the child must attend are all legitimate strategies to employ and legitimate starting
points for development of more comprehensive intervention goals and objectives.
This may require some flexibility on the part of school officials to give “tacit” approval of a child not being present for
the entire day. Even with a partial return to school, the ultimate goal is attending for a full day on a regular and
consistent basis. A plan should be in place to gradually increase attendance to a more normal pattern and not just
continue the alterations indefinitely. Identifying a gradually increasing expectation for normal attendance pattern does
not allow the child to become totally comfortable with a modified schedule.
The partial or full return to school may also be dependent on some environmental
shifts. This will require cooperation of school administration and may involve such
modifications as a schedule change, a teacher change, allowing the child to arrive at
the school through another entrance, allowing the child to arrive early, or allowing
him to arrive late. In these situations it is important to insure that the school
administration is in agreement with the intervention plan and the steps to achieving
full attendance. Mutual agreement on the part of both parents as well as mutual
agreement with school officials on a strategy of partial return is critical to prevent
the child from “splitting” parents or “splitting” parents and school personnel.
The following discussion of intervention strategies looks first at some general approaches or interventions frequently
employed with this population and then looks at specific interventions that work most effectively with the four different
purposes which school refusal might be serving.
Systematic Desensitization
The process of systematic desensitization is a long-standing behavioral strategy for dealing with an anxiety-based fear
response that is out of proportion to the actual stimuli. For many school refusers, anxiety about attending school is often
far in excess of what even they identify as reasonable. Systematic desensitization is the process of developing a fearproducing stimulus hierarchy of the feared aspects of attending school and then systematically pairing the items on the
hierarchy with deep muscle progressive relaxation, which is incompatible with an anxiety-based response. Gradually
working the child through her hierarchy of fears related to school and giving her the ability to regulate her response to
the feared situation may allow the child to return to school (King at al., 1998).
Exposure Therapy
Exposure Therapy has at its core the idea that habituation will occur with continued or prolonged exposure to an
anxiety-provoking stimulus. With a school refuser, the goal is to extinguish or diminish the fear response to attending
school through continual exposure. The exposure to the feared object (hallways, teacher, gym class, bathrooms, etc.)
can be in vivo with the idea of a gradual reentry to school and easing the child back into a classroom situation with
longer periods of exposure. Another exposure therapy approach is the idea of implosion or flooding. This is a rapid
reentry or exposure, with the assumption that the person subjected to prolonged exposure to the feared object or
situation will eventually habituate.
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Modeling Therapy
Modeling and role playing for school refusers has been particularly effective for those youth who struggle with the social
aspects of the school experience. Based on social learning theory, the premise is that by demonstrating or showing the
child non-fearful behavior options in anxiety-provoking situations, they may be able to copy the behaviors and develop a
repertoire of responses that will allow them to function in an anxiety-provoking situation. The modeling opportunity can
be presented in a number of formats, including video modeling, live modeling, and participant modeling, in which the
child observes another child modeling non-anxious behaviors and then performs the behaviors with the aid of the
therapist. This “seeing and then doing” approach has been most effective (Terry, 1998). In a less formal or structured
way, simply engaging in role playing activities and receiving immediate feedback can also have a very positive effect.
Cognitive Therapy
Cognitive therapy assumes that the child perceives some aspect of school attendance as threatening (to the child,
caregiver, or family) and feels incapable of managing the situation. By remaining at home, the problem is avoided,
anxiety is reduced, and school refusal is reinforced. Cognitive Behavior Therapy (CBT) has been shown to be effective in
treating school refusal (King et al., 1998 and Last, Hansen, & Franco, 1998). Wimmer (2003) reports that 83% of children
with school refusal behaviors treated with cognitive therapy were attending school at a one-year follow-up.
Silverman et al. (2008) concluded that sufficient information is available to include CBT as fitting the criteria for a
Possibly Efficacious Treatment for school refusal. A large part of providing cognitive therapy to this population is likely to
involve cognitive restructuring. Assisting children to identify self-statements that result in anxiety and then providing
them with a counter, contrasting the anxiety-provoking statements with alternative positive statements, is a way of
effectively changing many of the cognitive distortions at the root of their anxiety. The new cognitions may take the form
of a mantra, which can be repeated in a sub auditory fashion to decrease anxiety. Having the child keep a daily
behavioral and thought diary can provide some insight into the cognitive distortions that produce the anxious feelings.
Social Skills Training
One of the keys to eliminating school refusal may be to teach the child who struggles
with the social aspects of school concrete skills and techniques to increase her ability to
function in a social context. Social skills can be taught in a variety of concrete ways and
utilizing a variety of formats. Social skills groups of age-level peers, in which a child can
receive feedback about her social behaviors, are very effective. A trusted adult who
serves as a “social coach” can be effective in encouraging a child to engage in more
socially accepted ways and to experience positive social encounters at school. Verbal
skills and strategies that increase social effectiveness can be taught and encouraged. In
addition, teaching school refusing children to be aware of and to accurately read nonverbal cues and signs will increase social effectiveness (Kearney, 2008a).
Parent Training
For the group of school refusers whose purpose is attention seeking behavior (ASB), the bulk of the intervention may be
in helping the parents and school personnel to change their patterns of interaction with the child (Kearney, 2007a).
School refusal behavior is often a polarizing experience for parents, who may have very different approaches to handling
the problem. Parental involvement is a key indicator for success, because as long as the parents do not present a united
front and a consistent approach to the issue, the child will continue to divide and receive enormous attention,
sympathy, and involvement of at least one of his parents. Parent training often provides parents with a broader range of
parenting options and behavioral management strategies. Parent training may also have the benefit of reducing parents'
own anxiety, which will make them considerably more effective in intervening with their child.
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Educational/Supportive Therapy
Providing children and their parents with information about the nature of anxiety can be an effective intervention for
some school refusers. For many children, just understanding what is happening to them and normalizing anxiety as a
part of life can provide them with the opportunity to respond differently to attending school. Helping a child to talk
about fears and distinguish among fear, anxiety, and phobias can alleviate some of the panicky feelings they experience
in school. For some older children, journaling about their fears, thoughts, and coping strategies can be an effective tool.
Pharmacological Treatments
In general, the literature would seem to suggest caution in viewing medication as the first line of defense in treating
school refusal. Nevertheless, medication is occasionally the only intervention, or medications are used in conjunction
with behavioral and psychotherapy interventions. Although some authors have strong opinions that medication has no
place in the treatment of school refusal (Kearney, 2001 and Kearney & Albano, 2007), there are medications that are
prescribed for depression and anxiety. Some of those typically utilized include:
Tricyclics – Imipramine may be useful in some cases (Bernstein et al., 2000). Studies have indicated that a tricyclic
antidepressant may be more useful for children with better attendance records and fewer symptoms of social
avoidance and separation anxiety (Kearney, 2006b).
Selective Serotonin Reuptake Inhibitors (SSRIs) – Prozac (only SSRI approved for use with children under 12), Paxil,
Zoloft, Luvox, and other SSRIs are not recommended for children with a family history of Bi-Polar Disorder (Seidel
& Walkup, 2006).
Beta Blockers – Inderal (Propranolol) is effective at managing the physical symptoms of anxiety. Abrupt cessation of use
may trigger a hypertensive crisis.
Benzodiazepines – Ativan, Valium, Xanax may present possible physical and/or psychological addiction. Benzodiazepines
are not first line treatment because of concerns about dependence, withdrawal, and drug tolerance (Last &
Strauss, 1990). Because of the side effects and risk of dependence, benzodiazepines should be used for only a few
weeks, if at all (Riddle et al., 1999).
Kearney and Albano (2007) have expressed several specific
concerns about using medications as the primary intervention
for those youth struggling with school refusal. Their belief is that
medication may be appropriate in those cases where the level of
stress and duress is extremely high, but may actually be
detrimental for those school refusers whose distress is in a mid
range or low range. While children with extremely high levels of
distress may respond well, those with moderate distress may be
unresponsive or may experience significant side effects
(Kearney, 2006b).
While medication may be effective at moderating the physical
feelings of distress, they have limited or no impact on the
“thinking” or “acting” aspects of their distress. A child on
medication may feel physically better, but may still obsess about thoughts of not wanting to attend school or the
negative aspects of attending school. Medication may have little impact on well-established escape behaviors that are
firmly established through a reinforcement schedule that is self-defeating, even though the child feels less physical
distress while refusing to attend school (Kearney & Silverman, 1998).
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Family Therapy
Family therapy with school refusers may be an effective intervention. Typical family therapy allows for an exploration of
the purpose that the school refusal might serve in maintaining the equilibrium within the family system. Family therapy,
rather than focusing on the pathology or emotional issues of the school refuser, attempts to identify the ways in which
the family might be inadvertently or unknowingly rewarding, reinforcing, or encouraging school refusal. There are many
different forms of family therapy, but most have some dimension of examining the roles each family member plays,
responsibilities carried by each family member, the power dynamics within the family, and family communication
patterns. In addition, family therapy explores the family routines, the unwritten family rules, and who in the family has
the power to reward or regulate behavior. Many times a change in family dynamics or family functioning will extinguish
school refusal behavior in a family member.
Alternative Instruction
In some situations, the use of alternatives to traditional school-based instruction may need to be employed. These
situations should be viewed as temporary and transitional and not as a resolution to the problem, as the primary
treatment goal is an early return to school. Homebound instruction, online school, or other alternative instruction
processes will not resolve the school refusal behavioral issues. In some cases, the extra attention may make staying at
home more attractive and actually reinforce the school refusal behavior. Home schooling may mask the anxiety, but
does not deal with the underlying anxiety, and may actually result in further socially isolating the child.
The following is a chart complied by Kearney and Albano (2000) identifying a number of intervention strategies most
suited for each of the four types of school refusers.
Treatment of School Refusal
Function
Treatment Components
To avoid stimuli that provoke general negative affect (SPNA)
(crying, nausea, distress, sadness, and various phobias, i.e.
bathrooms, cafeteria, teachers, bullies, etc.)
Somatic control exercises such as breathing retraining and
muscle relaxation
Gradual re-exposure to school
Reduce physical symptoms and anticipatory anxiety
Self-reinforcement, self-talk, self-esteem
To escape aversive social and evaluative situations (EASE)
(social phobia, test anxiety, shyness, lack of social skills)
Role play
Cognitive restructuring of negative self-talk
Gradual exposure to real life situations
Social skills training and reduction of social anxiety
Coping strategies templates
To get attention (ASB) (tantrums, crying, clinging, separation
anxiety)
Parent training in contingency management
Clear parental messages
Evening and morning routines
Use of consequences for compliance/noncompliance
Forced Attendance
For positive tangible reinforcement (TROS) (lack of structure or
rules, free access to reinforcement, avoidance of limits)
Family contingency contracting to increase rewards for
attending school and decrease rewards for missing school
Curtail social and other activities for nonattendance
Alternative problem solving strategies to reduce conflict
Increase family communication skills
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Evidence for Utilizing Interventions Based on a Functional Model of School Refusal
The Functional Model of school refusal is based on a prescriptive identification of the purpose of the school refusal and
would appear to meet criteria to be considered an evidence-based treatment approach. The approach has been tested
in uncontrolled and controlled studies of prescriptive and nonprescriptive treatment (Chorpita et al., 1996; Kearney,
2002b and 2007b; Kearney, Pursell, & Alvarez, 2001; Kearney & Silverman, 1990, 1999). Kearney and Silverman (1999)
found that key measures in the functional model could accurately predict which prescriptive or tailored treatments
would be effective for a particular case.
A number of studies support the use of a Functional Model of school refusal behavior. Among a sample of 222 youths
with school refusal behaviors, Kearney (2007b) demonstrated that utilizing a structural model to find the function of
school refusal was a better predictor of school absenteeism than traditional measures of fear, anxiety, and depression.
Wimmer (2003) reported that 83% of children with school refusal behaviors treated with cognitive therapy were
attending school at one-year follow-up.
Silverman et al. (2008) reported that there is sufficient evidence to conclude that a cognitive behavior therapy approach
such as the Functional Model of School Refusal meets the criteria for consideration as Possibly Efficacious.
However, Kearney and Albano (2007) also recognized the need for ongoing research and further validation of this
approach. “Although the procedures have been shown to be highly useful for youth with psychopathology and school
refusal behavior, the functional model remains in development. As such, we encourage clinicians to utilize our guidelines
with appropriate caution. In addition clinicians should consider recommending adjunctive treatments such as
medication, family therapy, or educational interventions for learning disorders or classroom misbehavior as appropriate
and necessary.”
Specific Interventions that Work Most Effectively with the Four Purposes of School Refusal
The following information is an attempt to look at the phenomenon of school refusal and the specific interventions that
work most effectively with the four different purposes that school refusal might be serving. Interventions effectively
addressing the specific purpose of school refusal with one type of child may be inappropriate or ineffective with a child
whose school refusal is motivated by another purpose.
1) School Refusal for Avoidance of Stimuli That Provoke a Sense of General Negative Affect (SPNA)
Kelley is a seven-year-old child who is lying in the middle of the kitchen floor on Sunday night curled up in a fetal
position and moaning about how “ bad she feels.” She wakes up every school morning complaining about how she aches
all over, feels like she is going to throw up, and has a headache. Several visits to the pediatrician in the past month have
found nothing to indicate any significant organic basis for her complaints. She resists getting out of bed, dawdles, and
needs constant reminders to complete the next task of getting ready for school. She is resistive to attempts to help her
get ready for school and, the closer it gets to time to leave for school, the more generally resistive and distraught she
becomes.
Kelley reports not wanting to go to school for fear that something bad will happen and states: “whenever I’m at school I
feel yucky all the time.” When asked why she doesn’t want to go to school, she cannot give a logical reason except, “I
feel horrible when I’m there.” She complains that whenever she goes to school she feels sad and can’t help herself and
sometimes just starts to “cry for no reason.” She knows that most kids don’t really like to go to school, but for her it’s
just “awful and worse than it is for others.” She pleads with her parents to let her go to another school despite the fact
that all her brothers and sisters attend the same school quite willingly. In fact, Kelly had no problem attending the school
for kindergarten and first grade. Her parents are not willing to move her to another school, but in frustration are
considering home schooling “until she can get over the hump.”
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Treatment Components for SPNA
Children who are refusing school in order to avoid the stimuli associated with school (SPNA) and the accompanying
anxiety levels or state of general negative affect are primarily motivated by discomfort. They will engage in behaviors to
escape school or avoid it entirely. Interventions must attempt to alleviate the current state of distress, identify the
aspects of the stimulus that are producing the negative affect, and create changes at a cognitive, affective, and
behavioral level.
Pharmacotherapy for SPNA
Early treatment of school refusal typically involved a medical and pharmacological approach, primarily because
pediatricians and family care practitioners often served as the initial intervention agents. Children often developed
inappropriate escape strategies by feigning physical symptoms or may have misinterpreted the physiological
components of their anxiety as physical disorders or illnesses. Parents who had a child complaining about physical
ailments normally consulted the physician or pediatrician first. Once physiological issues and an organic basis for the
symptoms were ruled out, the assumption was made that the physical symptoms and accompanying school refusal were
fear- or anxiety-based. In many instances, the treatments involved using antidepressants or anxiolytics. During the 1970s
and 1980s there was significant support for using imipramine (tofranil), but is currently considered off-label for use with
children other than for treatment of enuresis.
Generally, it is probably best to avoid the use of any medication for treating school refusal unless there are extremely
high anxiety levels, the school refusal is comorbid with major psychological disorders, or unless the child has been
unresponsive to psychological treatment for school refusal in the past. Conditions like OCD, ODD, or major depressive
disorder usually require psychotropic medications. If medications are to be utilized, it is advantageous to use them in
combination with psychotherapy (Berg, 1997).
Tyrrell (2005) stated “youth with anxiety-based absenteeism respond ambiguously to medications, in part because of
the fluid and amorphous nature of anxiety and depressive symptoms in this population.” Kearney (2006a) reported that
the use of SSRIs has been found useful in youth with anxiety and depression with comorbid school refusal. Kearney
(2007a) concluded that several studies have shown that medications can be effective with children with high levels of
distress, as the medications ease the “physical feelings” of anxiety. He cautioned that the medications might ease the
“physical feelings” of distress without changing the cognitive or behavioral aspects of the distress. The child may
physically feel better, but may still have thoughts about not wanting to attend or continuing to refuse to attend school.
If pharmacological intervention is to be utilized, it is most likely to be effective with the child who is overwhelmed by the
emotional distress of attending school. However, medication should be reserved for those children suffering with
significant distress from underlying anxiety and depression and not the situational variables of school refusal (Kearney,
2007a). Utilizing medication for treating the underlying anxiety and depression may bring about relief for the school
refusal indirectly, but it would be hard to state that any medication is effective in treating school refusal behaviors,
particularly the non-anxiety-based types. Once again, it should also be noted that the most effective treatment for
anxiety and depression is a combination of medication and therapy.
For those children who have been on medication for anxiety and depression for a significant time and whose school
refusal continues to be problematic, it may be necessary to modify the medication regimen and introduce ongoing
psychotherapy to achieve a level of relief that allows the child to attend school. Other children may be in therapy for a
significant length of time for treatment of anxiety or depression, and yet continue to experience significant distress
when it comes to attending school. For them, the introduction of an appropriate medication regimen to treat their
anxiety and depression may be required. In either case, parents, school personnel, and mental health professionals
should be clear that the medication is being utilized to deal with the underlying anxiety and depression and not as a
primary treatment for school refusal.
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Cognitive-Behavioral Therapy for SPNA
School refusal behavior for many children and adolescents can be highly anxiety- and depression-based. Until
interventions appropriately address any underlying or comorbid anxiety and/or depression, it is unlikely that school
refusing behaviors will change significantly. A number of studies (e.g., King et al., 1998, Last, Hansen, & Franco, 1998,
and Wimmer, 2003) have demonstrated that classical cognitive-behavioral techniques are very effective at intervening
with this population. Cognitive elements have typically involved helping the child recognize and identify anxious feelings
and the somatic indicators of anxiety they experience while attending school. Walking a child through the process of
clarifying unrealistic or negative expectations and anxiety-provoking thoughts may be helpful in identifying the cognitive
distortions that the child is experiencing. In many instances, however, the child may lack the capacity for self-reflection
and may not be able to identify specific aspects of the school experience that are anxiety-provoking. In these cases, the
explanation may be limited to statements like “I don’t know,” or “school just makes me feel bad.”
If the child can assist in identifying some of the cognitions and cognitive distortions, the therapist or school counselor
may be of great assistance in helping the child to develop appropriate coping strategies. In those situations, positive selftalk, breathing, relaxation, distractions, etc. are very effective at reducing school refusal. A variety of options may be
attempted to develop coping strategies that are more appropriate than simply refusing to attend school. A plan of
action and intervention can be developed to insure an understanding of the various coping behaviors. Plans for selfreinforcement through new cognitions may reduce anxiety and discomfort, leading to feelings of self-efficacy.
Once cognitive components have been analyzed and
identified, it may be possible to attempt behavioral changes
that can lead to a more normalized response to the stimuli of
school attendance. Guided imagery or visualization of school
attendance can be useful in pairing new somatic feelings and
evaluations with the experience of attending school. Utilizing
in vivo exposure by gradually exposing the child to the stimuli
of the school experience may allow for desensitization to the
stimuli she has found to be unpleasant. This can be
accomplished through gradual, stepwise exposure to the
school building, hallways, and classrooms or through
gradually exposing the child to longer and longer periods in
the school setting (King et al., 2000).
Many particularly anxious and fear-based school refusers can
become overwhelmed with anxiety due to the complexity and ambiguity of the school situation and not having an
adequate experience base for attending school. Providing a model, such as an older sibling or “a buddy” who is
comfortable attending school, can be an effective means of handling the situation. Creating a fantasy or role-playing
situation in which the child can create her own scenarios with appropriate coaching may also be effective at lowering
overall anxiety. Exercises that provide the child some sense of control over somatic and affective experiences, such as
deep breathing or muscle relaxation training, may provide enough comfort that the child can cope with the discomfort
produced by the stimuli of school attendance.
Kearney and Albano (2007) and Kearney (2008a) have suggested that for this particular function of school refusal
(SPNA), the most effective strategy is leading the child through the process of identifying the “feeling, thinking, and
doing” of school refusal. First, assist the child in identifying his feelings, sweaty palms, queasy stomach, shaking hands,
rapid heartbeat, etc. and labeling those as things "I feel." Second, assist the child in identifying his thoughts and what he
is saying to himself, thoughts like “I’ve got to get out of here,” “I’m afraid,” “I want to go home,” “I need my mom or
someone to help me.” Finally, assist the child in identifying what he usually does in the situation of having to attend
school, such as leaving the room, going to the counselor’s or nurse’s office, crying, or throwing a tantrum.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 28 of 48
Once you have identified the affect, cognitions, and behaviors, it is possible for the child to learn about the nature of
feelings and modify his thoughts to be more appropriate and realistic through self-talk. He can begin to understand that
anxiety is the body’s way of preparing him to respond and can start changing some of the self-defeating behavior
patterns. Breathing, muscle relaxation, defocusing, and self-distraction can be effective ways of managing the “feeling”
part of their distress. In many situations, providing more positive and realistic thought patterns is effectively addressed
by changing the “thinking” by practicing self-talk.
Parents and school personnel should avoid truisms such as “There’s nothing to be afraid of,” “Suck it up and be a man,”
“You’re not really afraid,” or other statements that do not acknowledge the reality of the child’s discomfort. A more
effective strategy is to reframe the discomfort by acknowledging whatever realistic component may be there and then
normalizing it to make it more acceptable, temporary, transitional, and optimistic.
Finally, working with the “doing” part of the school refusal may require the parent and school personnel to tolerate
some behaviors on a temporary basis. They may need to modify the length, duration, and intensity of school refusing
behaviors while moving toward a goal of complete removal of school refusal behaviors and a full return to school.
Strategies like attending for part of the day, attending for favorite classes, limiting visits to the counselor or nurse on a
declining scale, or leaving the room for shorter time periods may be effective as first steps toward modifying some of
the school refusal behaviors.
Psychoeducation for SPNA
For some children, the experience of attending school is often their first major experience of anxiety that they cannot
avoid or escape. The experience of anxiety - with the accompanying somatic changes and affective discomfort - may be
overwhelming and sometimes misinterpreted as life threatening. In many situations, counselors can provide children
with an understanding of what is happening to them and reassure them that anxiety is not life threatening, but a normal
component of daily living. The counselor’s role may be to educate the youth regarding the various components of
anxiety, such as the nature of feelings, negative thoughts, somatic aspects, and negative behaviors.
The counselor can also teach the child that attempting to go through life
without ever experiencing anxiety is an impossible goal. Living necessarily
implies that all of us will - from time to time - experience the negative
physical, emotional, and behavioral components that accompany anxiety.
The counselor’s role in these situations is to teach the child to selfmonitor and understand the nature and severity of anxiety. The
counselor may also introduce the concept of gradual exposure to anxiety
and attaining a level of relative comfort, with the ultimate goal of full
attendance with manageable anxiety. The youth may benefit in other
ways by being empowered to cope with the normal levels of anxiety that
come with functioning in an age-appropriate fashion.
Building a Negative Affective-Avoidance Hierarchy for SPNA
Another effective method for helping children learn to manage their anxiety about school attendance is building a
hierarchy of anxiety-provoking situations (Kearney, 2001 and Kearney & Albano, 2007). Working through a hierarchy and
assigning a specific strength to the anxiety and fear associated with particular aspects of school attendance allows the
child to compartmentalize the problem and identify those aspects that produce the greatest discomfort. By being an
active participant in identifying the level of distress, the child can move away from a more generalized fear response.
The sorting and rating process also allows the counselor to assist the child in understanding the difference between (1)
an activity that produces actual “fear” and (2) an activity that does not produce a fear response, but that is undesirable
and that the child would prefer to avoid if possible.
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It is also helpful to assist the child in distinguishing between “can't” and "won't" situations. "Can't" situations are those
aspects of school attendance that produce such an overwhelming fear response that the child just “can’t” attend right
now. "Won't" situations, by way of contrast, are those that do not produce fear but that the child just “won’t” attend
because the stimuli are unpleasant or undesirable. At that point, it is possible to establish behavioral objectives that
address the avoidance behaviors. Simultaneously, the child and counselor can continue to work on developing the
coping skills necessary to approach some of the steps the child feels that she “can’t” do without extreme fear.
Somatic Control Exercises for SPNA
If we can demonstrate to the child that he can actively control and alter the negative feelings he has when attending
school, it will go a long way toward enabling him to endure the discomfort of school attendance. Stress reduction
exercises such as squeezing and releasing a “tension ball,” tearing paper into strips, and diaphragmatic breathing give
the child some sense of control over how he is feeling and reduce some of the “panic” of attending school. Muscle
tension and relaxation techniques can also be very effective in reducing the anxiety and bodily tension which the child
may be experiencing while attending school. Alternately tensing and releasing muscle groups can provide an active
strategy that the child can employ to manage his anxiety. The “Robot-Rag Doll” (Kendall et al, 1992) technique of tensing
all the muscles in your body and holding it for 10 seconds and then releasing the tension by becoming a rag doll is very
effective with younger children.
Formalized desensitization, either imaginal or in vivo, provides another way of managing the physical discomfort that
accompanies the anxiety of school attendance. Desensitization through the use of guided imagery (sights, sounds,
smells, feelings, places, and thoughts) is an effective starting point for a child who refuses school as a result of anxiety
that is related to the stimuli of the school environment. This can be done by asking the child to:
1) imagine a pleasurable image or scene in great detail until her discomfort level is negligible
2) begin to imagine various aspects of the stimuli of going to school
3) rate their level of discomfort on a scale of 1 to 100
When images of school attendance reach a discomfort level above 50, introduce breathing, relaxation techniques, or a
return to the pleasurable scene until they can return to a tolerable discomfort level. Teaching children to utilize these
techniques when they become anxious in school can be an effective intervention.
A similar approach can be to desensitize the child to the stimuli of school attendance by utilizing an in vivo approach.
Gradual exposure to the school building, with a similar rating of discomfort, and intervening with breathing, muscle
relaxation, habituation, or pleasurable images or fantasy can recondition the child to respond to the stimuli of school
attendance in a different fashion. Gradual exposure to elements of a real school setting (the bus, office, classroom,
teacher, etc.) and pairing those stimuli with a relaxation response will create a new stimulus-response contingency.
Some children may be able to attend school, but only with an inappropriate coping strategy such as sucking their thumb,
having a parent in the room, bringing a stuffed animal, etc. Desensitization techniques can include gradual removal of
safety objects or stimuli.
The following case study will provide an opportunity to develop an individualized strategic intervention plan as discussed
earlier. After the case description, there is a template which will facilitate the development of an intervention plan
based on:
1)
2)
3)
4)
identifying the purpose the school refusal serves
identifying any underlying or co-morbid conditions
establishing intervention goals
developing tentative objectives to achieve those goals
Sample answers are provided in Appendix A.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 30 of 48
“School Makes Me Want to Throw Up”
Eric Eggplant is an eight-year-old boy who has recently transferred to a new school. For the first three weeks of third
grade he spent only part of each day at school, either curled up in a ball on his classroom floor or trying to run from the
school building. Eric would awaken each morning with a stomach ache and then proceed to vomit. On days when he did
not vomit or his mother made him go to school he would fight her in the car or vomit in the parking lot. When asked
what the teacher did that was so mean, Eric could not give any examples.
His mother reports that the behavior started at the end of last year and attributed it to his teacher being a “witch.” At
the end of the year his mother sought to have him transferred out of the "school that had no feelings.” Eric stated that
his teacher this year is not mean, the kids are not mean, and he can think of no reasons why he can’t stay at school all
day, other than school “makes me want to throw up.”
Eric’s mother acknowledged that she had some difficulty getting him to go to school in kindergarten, but it quickly
faded. She attributed much of this to the teacher “who was an angel.” His mother has tried talking to him, “bribing” him,
punishing him, and refusing to come to school when Eric called complaining about being sick. The last episode, in which
he ran from the building, caused a great deal of alarm for his mother and the school administration.
This year has been particularly difficult for Eric as a result of his parents’ separation. Divorce papers were filed but
ultimately withdrawn as his parents try to work things out. Eric still wants his father to come home and live with them
and doesn’t understand why he won’t just move back in. He has been experiencing frequent nightmares and has
suddenly developed an extreme fear of thunder and lightning. He will no longer sleep in a dark room. Many nights, he
ends up in bed with his mother, which she states she allows simply “because it’s easier.” He has also regressed to
wetting the bed and refuses to do things by himself, even though his mother knows he is capable of doing them.
Type of School Refusal - Avoidance of Stimuli that Provoke a Sense of General Negative Affect (SPNA)
Underlying or Comorbid Conditions: ____________________________________________________________________
Goal 1: ____________________________________________________________________________________________
Objective 1: _________________________________________________________________________________
Objective 2: _________________________________________________________________________________
Objective 3: _________________________________________________________________________________
Goal 2: ____________________________________________________________________________________________
Objective 1: _________________________________________________________________________________
Objective 2: _________________________________________________________________________________
Objective 3: _________________________________________________________________________________
Goal 3: ____________________________________________________________________________________________
Objective 1: _________________________________________________________________________________
Objective 2: _________________________________________________________________________________
Objective 3: _________________________________________________________________________________
Goal 4: ____________________________________________________________________________________________
Objective 1: _________________________________________________________________________________
Objective 2: _________________________________________________________________________________
Objective 3: _________________________________________________________________________________
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 31 of 48
2) School Refusal to Escape from Aversive Social or Evaluative Situations (EASE)
Joseph is a 14-year-old boy who has just started his freshman year in high school and has started resisting going to
school. He reports being particularly nervous in classes where he has to perform in front of the class or do “group work.”
He has begun leaving school without permission after attending some morning classes. Joseph reports that he doesn’t
feel like he fits in at school and is frequently ridiculed by other students, particularly the “jocks,” who see Joseph as
weird and unmanly. Since he started high school three months ago, he has been a target of ridicule on Facebook and has
had videos which other students made of him posted on YouTube.
Joseph came from a small middle school where the staff and students were more accepting of Joseph’s “weird
statements” and his manner of dressing in very baggy and worn clothes due to his sensitivity to certain fabrics. In his old
school he had one or two “friends” but recently it has been reported that he talks to none of the students and is only
verbal as required with staff members. Joseph has become more resistive about going to school as “I get nothing out of
it, and I already know everything they can teach me.” He has been requesting that his parents allow him to withdraw
and take his high school courses on e-school.
Treatment Components for EASE
For these children, the place where they experience humiliation, ridicule, rejection, debasement, shame, and being
devalued is in the context of attending school. The child who is refusing school to escape from the Aversive Social and
Evaluative Situations (EASE) which come with attending school will engage in behaviors to escape school or avoid school
entirely. Intervention will need to attempt to alleviate the unpleasant social and evaluative components of school
attendance through changing social cognitions, providing social skills, creating the opportunities for social and academic
success, and gradual exposure to normal social situations.
Cognitive-Behavioral Therapy for EASE
Kearney and Albano (2000, 2007) and Kearney (2008a) have proposed the same kind of “thinking,” “feeling,” and
“doing” approach for dealing with school refusal that has at its core social anxiety and the fear of “measuring up” in
certain situations. The particular dysfunctional escape behaviors, in which these youth may engage to avoid the social
and evaluative components of school, can be displayed in a variety of ways. These might include walking the hallways
without speaking or making eye contact, hiding in the library or restroom during pep rallies or other group gatherings,
avoiding interactions with other students or staff members, refusing to participate actively in group discussions or group
projects, and avoiding or becoming ill when it is their turn to present in class or take a test.
These children who are refusing school may be attempting to
escape from an aversive situation which has very little to do with
the actual school or school setting. Their anxiety about attending
school derives from the fact that school is a social setting requiring
their interaction with peers and school personnel. The social
anxiety produced by the exposure to other children and unknown
adults is often a sufficient cause to avoid or refuse attending
school. The social anxiety may stem from a biological
predisposition toward anxiety, as well as faulty cognitions and
faulty self perceptions about social interaction in general and
school in particular. Until the social anxiety and fear of criticism or
ridicule has been resolved, it is very unlikely that these children will
be able to attend school without considerable anxiety or significant escape and avoidance behaviors. According to
Kearney & Albano (2007), this social anxiety and sensitivity to evaluation or criticism is best dealt with by using a
cognitive/behavioral approach.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 32 of 48
Children who avoid or refuse to attend school due to the social nature of the experience (EASE) have many cognitive
distortions about social interactions in general. The unstructured nature of the social exchange that takes place during a
typical school day may be particularly anxiety provoking. These youth may be overly sensitive to slights or comments
and have a cognitive frame which is rampant with distortions. Their belief that they are socially incompetent or that
other children are “out to get them” results in a negative frame that may become a self-fulfilling prophesy. Many of
these youth anticipate social rejection and either distort or misinterpret social stimuli or cues. They may lack the ability
to accurately perceive or decode social situations in an appropriate fashion. Characteristically, these children lack
effective communication skills and either over communicate or under communicate in social situations.
Changing their cognitions regarding the social aspects of school attendance may be very difficult, as these children often
have had limited success with social interactions and view themselves as “shy,” “socially awkward,” or “just different.”
Many may be unskilled or inexperienced at handling even simple social situations, conflicts, or interactions. Providing
training in social problem solving through a social skills group can alleviate some of the anxiety by giving them some
sense of competence and social success. Working with the school counselor to brainstorm hypothetical social situations
they might experience at school provides them the time to think through the situation, rather than have to improvise
behavior for every new situation. Having a counselor pose “hypothetical” social interaction situations and walking the
youth through possible responses, identifying the positives and negatives associated with each alternative, can also be
helpful in providing a sense of social competence through prior exposure.
Role playing potential social interactions in counseling may also be effective at reducing the discomfort these youth
experience in the social and evaluative context of school. Providing them the opportunity to practice various responses
in session, receiving feedback on how they handled the situation, and learning ways to improve their comfort in social
settings can be very reassuring. Additional specific training in identifying and interpreting facial cues, body language, and
other non-verbal aspects of human interaction and communication can also be very helpful in resolving the social
anxiety that accompanies school attendance.
Psychoeducation for EASE
Another potential intervention for this particular group of school refusers is to provide them with information about the
nature of social anxiety. This can be accomplished by educating the youth regarding the nature of feelings, negative
thoughts, somatic concerns, physical symptoms, and negative behaviors that comprise social anxiety. Providing them
with an alternative frame of reference regarding the feelings they experience in social settings can be very helpful. With
this type of training, children can begin to learn that the goal is not to avoid or limit the experience of social anxiety, but
to be capable of reading and understanding what their body is telling them. Totally eliminating social anxiety from their
life is unrealistic and may actually be counterproductive in the process of developing healthy psychological adjustment.
Teaching the child to distinguish between “normal” social anxiety and severe social anxiety is a key component to ending
the debilitation which these children experience. This can be accomplished by introducing the concept of gradual
exposure to social anxiety-provoking situations and the concepts of regression to the mean, habituation, and “fading” as
a result of acclimation. Pushing themselves to attend school and deal with a relatively uncomfortable level of anxiety for
a brief period may allow them to eventually attend in a fairly normal pattern with a fairly normal level of anxiety.
Building a Social/Evaluative Anxiety versus Avoidance Hierarchy (Kearney, 2007a and Kearney & Albano, 2007) can be an
effective tool toward normalizing social anxiety. For some children the social/evaluative anxiety may be so severe that
they cannot deal with a particular situation at this time. Other stimuli produce much less social/evaluative anxiety, but
are still undesirable and are avoided whenever possible. Chronic avoidance behaviors result in severe limitations in the
ability to function in a psychologically and socially typical fashion. Assisting the child with a sorting process that makes a
distinction between what is an overwhelming feeling of anxiety and what is avoidance begins to identify the aspects of
the school refusal that truly are a “can’t, at this time” versus those that are a “won’t because it’s uncomfortable or
difficult.”
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 33 of 48
The child rates various social/evaluative components of school attendance by placing them on a social fear thermometer
(rate from 1 to 100) and a discomfort or dislike level to clarify the stimulus value. Establishing the level of distress and
level of avoidance for a variety of social or evaluative situations in the school setting may allow the counselor to develop
interventions on lower value stimuli. This guarantees some movement on the school refusal behavior issue by modifying
or reframing the stimuli. The goal is to ultimately move the stimuli to a level that is acceptable to the child.
Cognitive Restructuring for EASE
In many instances, the youth may have created a series of social and evaluative cognitive distortions around attending
school, which make it difficult - if not impossible - for him or her to attend. Many children may catastrophize situations
involving a social and evaluative component to a level at which they are no longer comfortable or capable of attending
school. These negative cognitions about attending school are so extreme that a safer recourse is to limit the danger by
avoiding or refusing school attendance completely. Normal missteps in social functioning become disastrous public
humiliations, which are to be avoided at all costs. Failure to achieve at a certain level becomes an absolute confirmation
of their incompetence and deficiency. For many these social cognitions become a self-fulfilling prophesy leading to
further school refusal.
Negative thinking generally leads to poor performance. If the child thinks that he is socially incompetent, he will very
likely behave in a socially incompetent fashion. This negative perception, along with his internal thought process, will
create an interaction that is stiff and formal or awkward and bizarre, thereby decreasing the comfort level of the other
participant in the social interaction. This can lead to a downward spiral, in which the other participant’s discomfort with
this abnormal interaction pattern can cause them to reject or avoid interaction with the child who feels uncomfortable.
In turn, the child’s awareness of the discomfort the interaction creates in the other participant makes them even less
capable or interacting in a relaxed fashion, and the cycle continues to deteriorate.
They need to have the experience of more productive and fruitful social interactions that enable them to feel
comfortable and successful in the social aspects of attending school. The counselor can assist in training children to
restructure their thinking and feeling reactions by using simple anagrams to reflect on their experience and change their
thinking, feeling, and behavioral patterns such as FEAR (Kendall, et. al.1992) or STOP (Silverman & Kurtines, 1996).
FEAR - F what am I feeling, E what do I expect, A what actions and attitudes will help, and R what might be the results or
rewards
STOP - S are you scared, T what are you thinking, O what other thoughts and behaviors can you think of, and P praise
yourself and plan for the future
With older children you can use more traditional cognitive-behavior therapy (Beck, 1979) and focus on automatic
thoughts, all-or-none thinking, catastrophizing, negative labeling, cant’s, shoulds, won’ts, and mindreading.
Behavioral Exposures for EASE
Once the counselor has developed a hierarchy of social anxiety stimuli in the school setting, lower level anxietyproducing situations in the hierarchy can be targeted to gradual behavioral exposures. No matter how complex social
anxiety may be, the situation and stimuli can be broken down into smaller simpler steps and specific stimuli. In every
social situation, there must be the recognition that someone else is a part of the situation and stimuli. This recognition
may be as simple as making eye contact with another person or a verbal acknowledgment of the other person. Working
on a simple behavior such as increased eye contact and habituating to the discomfort of making eye contact can be a
first step to overcoming social anxiety. Using relaxation and self-talk techniques while attempting to perform lower level
anxiety-producing social interactions can help children overcome some of their anxiety about social or evaluative
situations and progress to the next level of anxiety producing interaction.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 34 of 48
Rehearsing social situations a youth is likely to encounter in the school setting with a group of accepting peers can
minimize the embarrassment factor and provide behavioral alternatives for handling difficult situations. The process of
behavioral exposure in a gradual, controlled fashion might go like this:
1) arm the child with a set of “conversation starter questions”
2) allow her to practice with adults or peers with whom she feels comfortable
3) attempt to start a conversation with an individual and then a small group
Breaking down the behaviors that are anxiety provoking into social tasks that are specific, concrete, time limited and
measurable may increase the social confidence of the child to a level where she can attend school with a normal level of
social anxiety.
The following case study will provide an opportunity to develop an individualized strategic intervention plan as discussed
earlier. After the case description, there is a template that will facilitate the development of an intervention plan based
on:
1)
2)
3)
4)
identifying the purpose the school refusal serves
identifying any underlying or co-morbid conditions
establishing intervention goals
developing tentative objectives to achieve those goals
Sample answers are provided in Appendix A.
“Everybody There Hates Me”
Nicholas Noodle is 14, and has just started his freshman year at a large county consolidated high school. The elementary
and junior high schools he attended were in a small rural mining town. Since the beginning of school, he has missed 23
days in the first quarter. Nicholas has stated that he hates the school, hates the kids, and hates the teachers, but cannot
provide any concrete examples or reasons for such negative feelings. His response to discussing the situation is
frequently, “everybody there hates me.” He says the kids there are not like him and go out of their way to make remarks
or make fun of him and his accent. He wishes the “old high school” had never been closed and consolidated with the
school in the city.
When Nicholas is at school he often arrives late for first period, which enables him to avoid hanging out in the halls with
the other kids. He is often found eating his lunch by himself in the library rather than going to the cafeteria. Given a
choice, he sits quietly in the back of class, never raises his hand to answer a question, goes mute when called on for an
answer, and has real difficulty working in small groups. He often is “sick” on days on which a test is scheduled and
refuses to make up the test at school. He would rather take a zero. Nicholas reports that he doesn’t know any of the
names of his new classmates and he has not made any friends since the start of school. If he talks to anyone it is the few
kids who are from his old junior high school, but even with them he often just stands on the edge of the group and does
not participate in the conversation.
When he stays home from school, he spends most of the day watching TV or playing video games. He is willing to do the
make-up work or homework, which he completes quickly and accurately. He takes the initiative to go on line and
download the class work and homework assignments and they are always completed by the time his parents get home.
Recently, to everyone’s surprise, Nicholas “cut” school, hitch-hiked home, and spent the day doing his class work and
homework. Despite being punished, he has continued to leave the school without permission, but always goes straight
home, despite the five mile walk. Other than cutting school, his parents report that Nicholas is not a problem and they
describe him as a quiet, respectful, and compliant child. He seldom gets in trouble at home and is generally very helpful
with the younger siblings. His parents are exploring the option of homebound instruction or allowing him to complete
his classes online.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 35 of 48
Type of School Refusal___ Escape from Aversive Social or Evaluative Situations (EASE)
Underlying or Comorbid Conditions: ____________________________________________________________________
Goal 1: ____________________________________________________________________________________________
Objective 1: _________________________________________________________________________________
Objective 2: _________________________________________________________________________________
Objective 3: _________________________________________________________________________________
Goal 2: ____________________________________________________________________________________________
Objective 1: _________________________________________________________________________________
Objective 2: _________________________________________________________________________________
Objective 3: _________________________________________________________________________________
Goal 3: ____________________________________________________________________________________________
Objective 1: _________________________________________________________________________________
Objective 2: _________________________________________________________________________________
Objective 3: _________________________________________________________________________________
Goal 4: ____________________________________________________________________________________________
Objective 1: _________________________________________________________________________________
Objective 2: _________________________________________________________________________________
Objective 3: _________________________________________________________________________________
3) School Refusal for Attention-Seeking Behavior (ASB)
Sam is an 8-year-old boy who has trouble attending school because he would much rather remain at home with his
father than go to school. Since Dad has been recently laid off from work, Sam has started to beg and plead to stay at
home with his Dad. When his father is successful in getting him to go to school, Sam obsesses all day long wondering if
his father will be waiting for him at the bus stop when he gets out of school. Sam begs and pleads with the office staff
and his teacher to allow him to call home to “check on his Dad.” On days when his father is able to get him to go to
school, there is typically a tearful scene in the parking lot or Sam refuses to get out of the car. Sam has actually left the
school grounds a number of times and walked home when he knew that his father was at home.
Sam has even threatened to hang himself with the car seat belt if his father makes him go in. Sam has also engaged in a
great deal of drama on school mornings with lots of tears, screaming, and being generally disruptive and disobedient.
Punishment for these behaviors has been unsuccessful. On at least two occasions Sam has hidden the car keys and
refused to tell his father where they were.
Sam's academic work is suffering now because he is not organized and is having difficulty concentrating and focusing.
Sam is very happy and content at home and on the weekends and even volunteers for “work projects” as long as he can
be with his father. Sam continually begs and pleads with his parents to withdraw him from school and allow his father to
home-school him “since he’s there anyway.” Short of that, Sam’s solution is to allow his father to come to school with
him and be the volunteer aide in the classroom.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 36 of 48
Treatment Components for ASB
For some youth, the purpose of their school refusal behavior is less about avoiding attendance at school and more about
gaining attention and recognition. Having an issue with attending school can be a very powerful way for the child to rally
the adults in his life to provide a great deal of care and concern. In many instances, parents and school personnel may be
inadvertently reinforcing the undesired school refusal by becoming overly involved or overly concerned. Much of the
intervention in these situations involves teaching the parents and school personnel to restructure the reinforcement
contingencies in a more appropriate fashion.
Restructuring Parent Commands for ASB
In some instances a parent may actually be an unwitting collaborator or co-conspirator in the child’s school refusal. For
example, there may be some parent-child interaction pattern that is reinforcing non-attendance. In such cases, it is very
important for parents to come to understand their role in maintaining the behavior.
It is very likely that the parents have discussed, begged, pleaded, cajoled, or even threatened the child with severe
consequences around the issue of the school refusal. In many instances what the parents are saying to the child is much
less important than the reward value of having the parents' complete attention and the child being in control of the
situation. Typically, for the child whose school refusal is about attention, no amount of lecturing, discussion, or promises
of rewards or consequences will be sufficient to change the behavior because the real reinforcement is the interaction
between the child and parent or child and teacher (Kearney, 2001).
Many parents may mistakenly feel that they can control the situation and manage the school refusal through their
verbal interaction with the child. They frequently resort to tactics like pleading, criticism, shame, sarcasm, ridicule,
excessive support, understanding, or lecturing. The counselor’s role in these situations is to assist the parents (and other
authority figures) in transforming long debates/discussions/pleadings into short commands and simple child responses.
Teaching parents how to be "parental," and giving them permission to act as authority figures may also be critical to
managing the school refusal behavior.
One important step is to assist parents in learning how to identify key errors in parental commands. Ineffective
commands are 1) question-like (Do you think you’ll be able to go to school today?), 2) vague (It’s 7:30), 3) incomplete
(find your backpack), or 4) multi-step or excessively long (get your backpack, empty the dishwasher, help your brother,
get to the bus stop, and help me find your library books). Such commands are almost guaranteed to spur noncompliance.
The most effective techniques involve issuing simple, direct commands that move the child toward behaviors resulting in
attendance at school. Many school refusers realize that passivity is their greatest weapon in increasing the likelihood
that they won’t be required to attend school. It also increases the likelihood that the child will receive attention, albeit
negative attention. Parents should be coached in how to deal with passivity in a non-attending, non-reinforcing fashion
and always be prepared with consequences for non-compliance (Heyne & Rollings, 2006).
Ignoring Simple Inappropriate Behaviors for ASB
Since the purpose of the school refusal for these children is to obtain attention and connect with parents, any response
that reinforces inappropriate behavior should be avoided. Lecturing, yelling, negotiating, trying to calm, or using physical
force are inappropriate for intervening with attention seekers. Such behaviors only serve to reinforce the unacceptable
behavior. Whenever possible, ignore inappropriate behaviors. The counselor’s role may be to teach parents to avoid
reinforcing inappropriate behavior by averting eye contact, “going silent,” looking over or through the child,
administering a “time out,” isolating the child from attention and interaction, or attending to siblings and other activities
(Kearney and Albano, 2007).
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 37 of 48
Parents may also have to develop a capacity to ignore physical complaints that are not grounded in some demonstrable
symptom. Utilizing the criteria of the three B’s, “if you are not burning, bleeding or broken you must attend school”
provides a way of avoiding the endless debates over psychosomatic physical symptoms. Even when the child is
legitimately sick, the counselor can encourage parents to show little physical or verbal attention, and the child must
remain in bed during school hours in order to avoid reinforcing being sick as a way of avoiding school.
Establish Fixed Routines for ASB
The child who is seeking attention through his or her school refusal (ASB) may engage in a variety of escape and
avoidance behaviors that are extremely disruptive and frustrating. Creating chaos or some type of scene every morning
is doubly reinforcing because it requires attention from the parents and, if successful, enables the child to escape
attending school. Encouraging parents to develop a rigid morning routine that does not vary and cannot be derailed by
the child’s disruptive behaviors will be very important in insuring that the child makes it to school in the morning.
Requiring the child to awaken 90 – 120 minutes before the start of school provides a “cushion” to deal with the
disruptive behaviors.
The counselor can also be of assistance by reframing the parents' concern about being tardy or late into "it’s important
to get the child there no matter what time they arrive.” Encouraging parents to insure that the message the child
receives is “you will eventually be required to go to school no matter how much you delay or are disruptive” is a key
toward changing the child’s response pattern. If the parent is absolutely unable to require the child to attend, daytime
contact with the child should be limited, and the evening should focus on completing homework and “serving time for
missing school” with absolutely minimal contact with the parent. Establishing a point system for behaviors necessary for
school attendance with appropriate consequences and rewards may be an effective way to change the response
patterns and the parent-child dynamics.
Excessive Reassurance-Seeking Behavior for ASB
Another delay or avoidance tactic utilized by many of these children (ASB) is repeatedly and excessively asking for
reassurance. If successful, this serves as a dual reward system because it elicits attention from a parent who feels the
need to give reassurance to the child and, if exercised sufficiently, may delay or prevent the child from attending school.
Frequently the child may ask the same question, or make the same plea, over and over in a never ending stream of
“what ifs.” If the parent continues to interact with the child in this manner, he or she becomes complicit in helping the
child avoid the possibility of actually going to school in a timely fashion. Parents can avoid this trap by answering the
question only once, reminding the child on the second attempt that she already knows the answer, and then ignoring all
subsequent attempts to ask another version of the same question.
In a similar vein, the child at school may also request frequent calls home to seek reassurance. These behaviors should
be placed on a diminishing reinforcement schedule. Calls in excess are grounds for punishment that night. Days without
calls home should be reinforced with an appropriate recognition and reward. Rewarding a “call-free day” with one-onone attention gives the child attention for appropriate behaviors rather than for inappropriate ways of seeking attention
and connection to the parent (Kearney, 2001).
The following case study is offered as an opportunity to develop an individualized strategic intervention plan as
discussed earlier. After the case description, there is a template that will facilitate the development of an intervention
plan based on:
1)
2)
3)
4)
identifying the purpose the school refusal serves
identifying any underlying or co-morbid conditions
establishing intervention goals
developing tentative objectives to achieve those goals
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 38 of 48
“Can’t I Stay at Home and Have You Teach Me?”
Rebecca Rigatoni, an 8-year-old girl, has always had difficulty attending school, but did attend with much coaxing and
encouragement until she started the third grade. Since then, the problem has worsened significantly. She begs to stay
home from school, and when her pleading does not work, she resorts to screaming, being oppositional, and resisting
getting dressed. The combination of these behaviors often results in her missing the bus. Rebecca insists that she
doesn’t want to go to school because it makes her feel sad and afraid. She cannot identify anything or anyone at school
that makes her fearful and insists her teacher and the other students are “nice.” Her mom frequently resorts to taking
her to school in the family car, and Rebecca has piled up a number of tardies. Rebecca knows her mother is a former
teacher and she wants to stay home and have her mother teach her what she needs to know.
Upon arriving at school, Rebecca frequently begins complaining that she is sick and asks to go to the office. She is on a
first-name basis with the office staff and attempts to get them to call her mother to pick her up. Sometimes simply
talking to her mother will enable her to return to class. If she is sent back to her classroom, she frequently returns to the
office during the next period. At least twice a week, her mother relents and picks her up. When she gets home, she
usually spends the time in the presence of her mother playing quietly or watching TV. Rebecca’s solution to the problem
is for her mother to get her a cell phone that she can take to school. This is a violation of school policy. Her teacher
indicates that Rebecca is a good student, and somehow manages to keep up academically in spite of her frequent
absences. She is cooperative and pleasant unless the teacher refuses to let Rebecca go to the office. Then she can
become quite difficult and tearful.
Mrs. Rigatoni reports that Rebecca often tells her that she would rather be at home than go to school and that when she
is at school all she can think about is her mother and baby brother. Mrs. Rigatoni had taught school prior to the birth of
her children, and Rebecca has often insisted that she could teach Rebecca at home. Rebecca has a number of friends in
the neighborhood, but gets into moods in which she won’t leave the house and follows her mother from room to room.
Type of School Refusal: Attention-Seeking Behavior (ASB)
Underlying or Comorbid Conditions: ____________________________________________________________________
Goal 1: ____________________________________________________________________________________________
Objective 1: _________________________________________________________________________________
Objective 2: _________________________________________________________________________________
Objective 3: _________________________________________________________________________________
Goal 2: ____________________________________________________________________________________________
Objective 1: _________________________________________________________________________________
Objective 2: _________________________________________________________________________________
Objective 3: _________________________________________________________________________________
Goal 3: ____________________________________________________________________________________________
Objective 1: _________________________________________________________________________________
Objective 2: _________________________________________________________________________________
Objective 3: _________________________________________________________________________________
Goal 4: ____________________________________________________________________________________________
Objective 1: _________________________________________________________________________________
Objective 2: _________________________________________________________________________________
Objective 3: _________________________________________________________________________________
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 39 of 48
4) School Refusal for Tangible Reinforcers Outside of School (TROS)
Maya is a sixteen-year-old female in her junior year at a local high school. Maya has had no real attendance problems
until this year when she began hanging out with a new group of friends. She most typically comes to school in the
morning “to see her friends.” She insists that school has nothing to offer her, and complains that "all day long they make
me do boring stuff.” Her friends often encourage her to “cut” class and go to the local mall with them. As a result, her
grades are suffering.
Maya reports no particular distress about attending school, but doesn’t see it as a particularly useful activity. She has
even gotten other youth to get the assignments for her and occasionally she does them at home and then has someone
turn the work in for her. As a result, her absence at school is not always noted and she continues to be in places other
than at school. When her parents challenge her absence at school, Maya actively insists that she was at school and says
“I can get four of my friends to swear I was there today.” The school also has a number of her written excuses for leaving
school early that look very suspicious. Maya is very popular with her peers and is considered “the life of the party.” On
one of her absences, she was accused of shoplifting at the mall, and when her parents were called, they talked the store
personnel out of filing charges. As a result of that incident she is “grounded for life” and her parents have taken away
her cell phone and her ability to text her friends.
Treatment Components for TROS
For this particular group of children, the school refusal is less anxiety-based or attention-based and more about
controlling the environment and the demands made on them for school attendance (Kearney, 2008a). School
attendance may not be a particularly rewarding experience for these youth, and often other concrete reinforcers in the
environment may be pursued rather than attending school. This struggle for control and for controlling the environment
often leads to highly conflictual situations. Because antagonism, conflict, and poor problem solving are common in many
of these families, the intervention goals typically involve enhancing the family’s ability to effectively resolve conflict
around the school refusal. The components of functionally based treatment for this group of school refusers include
contracting, escorting the child to school, communication skills training, and peer refusal skills training.
Contracting for Attendance for TROS
For a number of reasons, contracting for school attendance is typically a very complex process. First, many families have
developed a dynamic of mutual distrust between the child and the parents. Both parties often have presented “empty
promises” in the past, and an attitude of mutual distrust makes contracting for anything a highly suspicious and tenuous
activity. By the time the youth is capable of opting for more rewarding situations by refusing to attend school, the ability
of the parents to require school attendance is minimal, at best.
Second, due to the level of conflict in these families, initial and subsequent contract negotiation may have to take place
under the supervision of a therapist or counselor working with the child and family. In order to effectively contract with
the youth, the first step may be to reestablish the belief that both the child and his parents are capable of effectively
negotiating and honoring a contract. The first contract should involve an easily defined problem which has little to do
with school attendance, such as chores, curfew, personal responsibility, etc.
Kearney (2001) has suggested that for the first contract, simplicity is the key. Parents and youth should not attempt to
tackle convoluted, complex, or volatile situations. The idea is to generate as many solutions as possible to a very
concrete problem and try to have all parties arrive at a consensus. Once some agreement is reached, the child and
parent attempt to define rewards for compliance and consequences for non-compliance. The first contract should be 1)
simple and straightforward, 2) last no longer than 2-3 weeks, 3) eliminate all loopholes or excuses, and 4) have exact
definitions regarding timelines, responsibilities, and criteria for successful completion.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 40 of 48
If parents and the youth can successfully negotiate and conform to the specifications of a simple contract, then an
attempt at developing a contract for school attendance can be negotiated. The school attendance contract should only
be attempted after a successful first contract and at a time when there is not severe conflict existing between parent
and child. The contract may have to be stepwise and establish the beginning elements of a precursor to full attendance.
Full attendance may need to be phased in initially to insure compliance and increase the possibility of success. The
contract should also require completion of chores and school work at home. Linking attendance at school with the most
powerful positive reinforcers (e.g., extension of curfew, sleepovers, additional time with friends, shopping, video games,
phone, computer, rides for friends, tattoos, use of family car, etc.) increases the likelihood of success. Parents may also
wish to link attendance with the opportunity to earn money or additional privileges by completion of chores, contingent
on attendance of school. The following is a sample of a typical school attendance contract:
School Attendance Contract
In exchange for decreased family tension and a resolution to the school problem, all family members agree to
try as hard as possible to honor the contract.
In exchange for the privilege of being paid $25 for cutting the grass and feeding the dog, Bobby agrees to attend
school each day from 10 to 2.
Should he not complete his responsibility he will cut the grass and feed the dog without being paid.
Should he not complete these chores Game cube will be removed for 1 week.
In exchange for the privilege of playing football Bobby agrees to attend school each day from 10 to 2 and be
ready to leave for school by 9:30 (dressed, hair combed, teeth brushed, and backpack with all homework).
Should he not complete his responsibility he will be required to attend school “as is” and not attend football
practice or play on Saturday.
In the event that all terms of the contract are honored from Monday 9:30 am to Friday 6:00 pm Bobby will be
transported to Blockbuster and allowed to rent any non-M game of his choice.
Bobby and his parents agree to uphold the conditions of the contract and read and initial it each night before
going to bed and each morning before going to school.
_______________________________________________
Date: ___________________
_______________________________________________
Date: ___________________
_______________________________________________
Date: ___________________
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 41 of 48
Communication Skills Training for TROS
Kearney and Silverman (1995) reported that many of these children are from families in which poor communication is a
major issue. This will likely make contracting and negotiating a contract for school attendance very difficult. Initial efforts
may focus on basic interactional problems such as interrupting, poor listening, silence, refusal to communicate, and
arguing. A family therapist or counselor can help establish communication rules during the negotiation of the contract:
i.e. no insults, no sarcasm, low volume, etc. It may be necessary to utilize mediation and negotiation techniques by
initially working with various dyads and triads within the family to minimize conflict and establish a workable contract.
Total effective family communication may become an issue for counseling once some level of agreement and trust has
been reached.
Peer Refusal Training for TROS
Peer influence may be more motivating than any reinforcers that could be established in a school attendance contract.
Many children may not be attending school because they are being influenced by their peers to “ditch” or “cut” school.
Peer refusal training is most useful for those who intend to stay in school, but succumb to pressure to leave early or to
never arrive at school and meet their peers at some other location. The counselor can be effective by obtaining a
description of what peers are saying or doing to entice non-attendance and providing the youth with rebuttal
statements through modeling and role playing. A workable strategy to respond to peer pressure without social ridicule
or rejection may reduce absences.
Practical Strategies for School Personnel and Parents
Forced School Attendance
If a child is completely absent from school, has been chronically missing for a significant portion of the time, or other
attempts at producing a change in behavior have failed, it may be appropriate to begin thinking about ways to physically
take the child to school. Forced attendance is viewed as a “flooding” procedure with the goal of eventually creating
habituation and a successful adaptation to attending school. Originating in the mid-60s, forced school attendance was
reported to be a very successful behavior modification technique. Kennedy (1965), in a limited sample study, reported
100% success for first episode of school refusal. While no technique is 100% successful, this technique has been
replicated frequently enough to warrant consideration.
Key to this approach is the concept of habituation, which can be accomplished
through gradual desensitization or by “flooding” the organism with the feared stimuli
until habituation takes place. School personnel and parents are encouraged to “keep
the child there” by whatever means necessary. While this is not a license to be
physically or verbally abusive, it may be necessary to use safe physical management
techniques. This technique requires an adult who is able to ignore somatic
complaints or disruptive behaviors and simply require compliance with the directive
to “sit at your desk.” The technique requires a good working relationship between
the parents and school personnel, as there may be a period of significant disruption
to the classroom and acting out at home until the habituation takes place.
Forced school attendance requires some caution with those children whose school
refusal behavior is highly anxiety-based, i.e. children who are attempting to avoid stimuli that produce significant
negative affect (SPNA) and those youth who are attempting to avoid the negative social and evaluative aspects of school
attendance (EASE). In some instances, attempting to use this technique with such youth may actually result in
traumatizing the child and creating more significant and pathological resistance (Kearney and Albano, 2000).
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 42 of 48
Steps for Forced School Attendance (Kearney and Albano, 2007)
Parents prepare the child for school – physically, if necessary >>> Issue a command for the child to go to the car or bus
“or we will take you” >>> If the child refuses, issue a warning >>> If refusal persists, parents physically carry the child to
the car (one drives: one manages misbehavior in the back seat; no physical or emotional abuse) >>> Ignore
inappropriate behavior, work through tantrums, and maintain a neutral demeanor >>> Upon arrival at school, issue the
command to leave the car and go to school >>> If refusal persists, parents and school personnel physically take the child
into the building.
Forced attendance is most effective for those youth whose school refusal behavior is attention-based (ASB). As a result
of the potential for misuse of this technique, Kearney and Albano (2000) developed guidelines for the use of forced
attendance. Their guidelines indicate that this technique is only appropriate when:
•
•
•
•
•
•
•
•
The child is refusing school the majority of the time and other interventions have been unsuccessful.
The child is refusing school only for attention (AS) and has little distress or anxiety about attending school itself.
Parents must be willing to take the child to school and school officials must be willing to meet the child at the door
and serve as “escorts” and even supervise classroom behavior.
Two parents or one parent and another trusted adult take the child to school to manage misbehavior (and then
leave).
The child is clear about the consequences of what happens if he or she refuses school.
The child must be under 11 years of age.
Parents and school personnel must be willing to expend the considerable effort this technique requires.
Parents and school personnel understand that some children are quite “strong willed” and the procedure may takes
several days or even weeks. Parents must be warned in advance about the risk and danger of stopping the technique
prematurely and the conditioning contingency that is established if the child is reinforced by getting his way for
“outwitting and outlasting” the attempts of adults to make him compliant.
Escort Services
Escort services entail a process that is particularly effective with middle and high school aged
youth who are refusing school to obtain other tangible rewards (TROS). The process involves
a parent actually accompanying the child to school and remaining with her for the entire day.
The escort accompanies the child to school, to and from each class, and to all school
activities, including lunch and other less structured activities like gym and physical education.
Obviously, this technique works best for a child seeking tangible reinforcers (TROS) and not
with a child who is an attention seeker (ASB). Children who are attention seekers may
actually welcome the idea that their parent would accompany them to school.
This is a technique that should never be used as a “bluff” or threat. Some children may be so
oppositional that they will “call your bluff.” Even those children who “call your bluff” typically
can not last more than one or two days with their parents attending school with them before
they will acquiesce to attending school. In most situations, the credible threat of escorting and accompanying a child to
school creates enough social apprehension to obtain school attendance (Kearney, 2001).
Escort services require the cooperation of school officials who are willing to have parents in their school in a
“supervisory” capacity. Ideally the “escort” might be a non-parent, aunt/uncle, grandparent, or the parent least
emotionally involved with the child. Grandparents can be particularly effective, as many of them have the time and
commitment to the child to actually carry out the escorting services. In order to counter-balance the negative
components of being escorted, the child must have the ability to obtain rewards for attendance once his behavior is
back under self-management.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 43 of 48
Suggestions for Parents
Parents play a crucial role in the management and redirection of school refusal behaviors. It is important to have both
parents actively involved even when custody is split or joint. Not allowing the child to triangulate parents around the
issue of school refusal behavior can be the parents’ most effective intervention.
Specifically, parents can:
 Believe that your child will get over the problem and let him know that you believe he can handle it.
 Listen to your child and encourage him to talk about his fears at times other than when you are attempting to obtain
school attendance.
 Be understanding, use reflective listening, and don’t use shame.
 Maintain good contact with school and teacher.
 Make sure that the child knows you will return to pick him up or that he will receive adequate supervision after
school.
 Prepare the child with gradual separations.
 Inform him that you expect him to stay for the entire day.
 Leave quickly (don’t look back or hover).
 Do not reinforce the child’s distress by rescuing him or her.
 Tell the child you will be doing something boring at home.
 Be reliable and on time when picking up your child.
 Have the other parent, a relative, a neighbor, or someone else who is less emotionally involved with the child take
the child to school.
 Let the child have something of yours to keep in her pocket i.e. a symbol or picture.
 Give the child as much control as possible by providing the illusion of control (Do you want to wear your green
sweater or red shirt when you go to school today?).
 Prolonged goodbyes don’t help the situation. A firm, caring, and quick separation is best for all concerned.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 44 of 48
Appendix A: Sample Case Study Responses
Eric Eggplant: School Makes Me Want to Throw Up
Type of School Refusal: Avoidance of Stimuli that Provoke Negative Affectivity
Underlying or Comorbid Conditions: Generalized anxiety disorder, parental conflict, dependency issues, specific
phobias, enuresis
Goal 1: Decrease General Anxiety and Activation Levels
Objective 1: Confront irrational fears and beliefs
Objective 2: Provide instruction around relaxation techniques and self-talk
Objective 3: Provide a set of specific coping strategies to use at school
Goal 2: Reduce Reactivity to School and Negative Affect Regarding School
Objective 1: Establish an Affective/Avoidance Hierarchy
Objective 2: Institute imaginal desensitization procedures
Objective 3: Institute In-Vivo desensitization procedures
Goal 3: Determine the nature of physical symptoms
Objective 1: Refer for physical examination to rule out organic basis
Goal 4: Increase school attendance and length of time at school
Objective 1: Establish a reward contingency for school attendance
Objective 2: Establish a consequence contingency for school refusal
Goal 5: Increase autonomy and decrease dependency on mother
Objective 1: Participate in family therapy to restore hierarchy/structure
Nicholas Noodle: Everybody There Hates Me
Type of School Refusal: Escape from Aversive Social or Evaluative Situations
Underlying or Comorbid Conditions: Social phobia, rule out dysthymia
Goal 1: Identify social situations which produce anxiety
Objective 1: Establish anxiety and avoidance hierarchy
Objective 2: Determine anxiety “triggers”
Goal 2: Increase social skills and comfort in social settings
Objective 1: Participate in a formal social skills group
Objective 2: Challenge social misperceptions and increase communication skills
Objective 3: Provide relaxation training and social skills role modeling
Objective 4: Provide social support from other students through mentoring
Goal 3: Provide information regarding the nature of social anxiety
Objective 1: Parents to participate in psychoeducation classes
Objective 2: Educate the child regarding the nature of social anxiety
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 45 of 48
Goal 4: Challenge Cognitive Distortions about new school setting
Objective 1: Reduce catastrophic thinking
Objective 2: Increase positive self-talk
Objective 3: Analyze the impact of all-or-none thinking patterns
Rebecca Rigatoni: Can’t I Stay Home and Have You Teach Me
Type of School Refusal: Attention Seeking Behaviors
Underlying or Comorbid Conditions: Separation anxiety, rule out oppositional defiant disorder
Goal 1: Decrease Anxiety around separation issues
Objective 1: Confront irrational fears and beliefs
Objective 2: Provide instruction around relaxation techniques and self-talk
Objective 3: Establish a symbolic connection with parent
Goal 2: Increase school attendance
Objective 1: Establish a reward contingency for school attendance
Objective 2: Establish a consequence contingency for school refusal
Objective 3: Develop a standardized “morning routine” with predictability
Goal 3: Determine the nature of physical symptoms
Objective 1: Refer for physical examination to rule out organic basis
Goal 4: Coordinate with school for consistent plan to address in class behavior
Objective 1: Develop “allowance” plan for contacting mother during school hours
Objective 2: Develop communication and feedback system for school and home
Objective 3: Establish consequences to extinguish attempts to leave school
Author Bio:
George B. Haarman, PsyD, LMFT, is a Licensed Clinical Psychologist and a Licensed Marriage and Family Therapist
currently in private practice. He received his doctorate in clinical psychology from Spalding University and is a member
of the American Psychological Association. Dr. Haarman has been an instructor at Jefferson Community College,
Bellarmine University, and Spalding University. He has presented seminars regionally and nationally on psychopathology,
depression, and emotional disorders in children and adolescents. Dr. Haarman serves as a consultant to several school
systems regarding the assessment of children. His prior experience includes working with youth detention centers,
juvenile group homes, child protective services, and juvenile probation.
© 2011 George B. Haarman, PsyD, LMFT | www.pdresources.org | #40-29 School Refusal Behavior | Page 46 of 48
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